MPPS Policy Customization Lead Director

CVS Health•Work At Home-Missouri, MO

2d•$100,000 - $231,540•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Lead Director, MPPS Policy Consultation, directs medical, clinical, & payment policy SAI (Scorable Action Item) processes, leading teams to execute projects from initiation through completion. Collaborates cross-functionally as an expert policy advisor with clinical, coding, operations, compliance and technology teams to deliver value to the organization. Secures required resources and formal processes and tools to manage resources, budgets, risk, and changes. Assesses roadblocks to ensure on-time completion according to specifications and within budgeted costs. Collaborates as expert policy advisor with stakeholders (ie: Medical Economics, product lines, Network) to develop strategic plans for projects and programs delivering high-impact outcomes to improve policy performance, claim accuracy, and regulatory compliance. Prepares & presents SAI progress reports to stakeholders and senior management. Administers areas for continuous improvement in SAI lifecycle and ensures compliance, high performance standards, and quality outcomes. Policy Development & Implementation Directs research, authoring, evaluation, & implementation of medical, clinical & payment policies bringing new value to the organization Makes certain policies are driven by evidence-based practices and supported by federal & state regulations Aligns with PI COE and other internal and external stakeholders throughout implementation, establishing clear business requirements and coding architecture for accurate configuration and operational success Leverage data-driven insights to inform strategic decisions and improvements Provides operational review teams direction on how to interpret policies for accurate review People, Program & Project Leadership Directs and mentors a high-performing team of MPPS policy clinical and coding subject-matter leaders, project managers and/or project coordinators Directs a portfolio of complex, cross-functional projects supporting MPPS initiatives throughout project lifecycles (intake, planning, execution, monitoring, closure) Ensure projects are delivered on time, within scope, and aligned to business and regulatory objectives Directs adoption of standardized project management methodologies (e.g., Agile, Waterfall, hybrid) Implements continuous improvement initiatives to enhance delivery efficiency and quality Develops and maintains tools, templates, and SOPs to support consistent execution Stakeholder Engagement, Governance & Transparency Communicates with executive leadership as medical coding & policy expert Facilitates governance forums, decision-making bodies, and cross-functional working sessions Communicates program status, risks, and key decisions clearly to senior leadership & stakeholders Administers quality oversight of SAI initiatives, ensuring policies are performing financially and operationally as expected Establishes and tracks key performance indicators (KPIs) for project and program success Regulatory Affairs & Compliance Leads team of policy experts who support and provide expert testimony during regulatory investigations, state fair hearings, and CMS audits. Implements proactive issue resolution and escalation strategies Ensures audit readiness and compliance with internal controls and regulatory requirements Deliver executive-level reporting on SAI progress, outcomes, and operational impact

Requirements

10+ years of experience in project or program management
10+ years of experience within healthcare (health plan, payer, or related environment), with emphasis on medical policy, payment integrity and improvement of cost of care
Strong understanding of Medicare and Medicaid regulations
Demonstrated expertise leading cross-functional initiatives impacting operations, policy, or compliance
Adept at execution and delivery (planning, delivering, & supporting)
Advanced project/program management expertise across large-scale, cross-functional initiatives
Mastery of problem-solving, prioritizing and decision-making skills in a fast-paced environment
Mastery of growth mindset approach (agility with developing self and others)
Bachelor’s degree in business administration, Healthcare Administration, Public Health, or related field required or equivalent experience
Medical coding certification (ie: CPC, CCS, CPMA, RHIT) required or must obtain within 1 year of employment.

Nice To Haves

Experience in medical policy, payment policy, claims operations, or utilization management
Experience with Lean Six Sigma, process improvement, Agile and hybrid delivery models
Experience supporting regulatory or audit-driven initiatives (e.g., CMS, HIPAA)
Experience with SAI system implementations, configuration, or policy deployment initiatives
Clinical licensure (ie: RN, LPN, PA) preferred

Responsibilities

Directs medical, clinical, & payment policy SAI (Scorable Action Item) processes, leading teams to execute projects from initiation through completion.
Collaborates cross-functionally as an expert policy advisor with clinical, coding, operations, compliance and technology teams to deliver value to the organization.
Secures required resources and formal processes and tools to manage resources, budgets, risk, and changes.
Assesses roadblocks to ensure on-time completion according to specifications and within budgeted costs.
Collaborates as expert policy advisor with stakeholders (ie: Medical Economics, product lines, Network) to develop strategic plans for projects and programs delivering high-impact outcomes to improve policy performance, claim accuracy, and regulatory compliance.
Prepares & presents SAI progress reports to stakeholders and senior management.
Administers areas for continuous improvement in SAI lifecycle and ensures compliance, high performance standards, and quality outcomes.
Directs research, authoring, evaluation, & implementation of medical, clinical & payment policies bringing new value to the organization.
Makes certain policies are driven by evidence-based practices and supported by federal & state regulations.
Aligns with PI COE and other internal and external stakeholders throughout implementation, establishing clear business requirements and coding architecture for accurate configuration and operational success.
Leverage data-driven insights to inform strategic decisions and improvements.
Provides operational review teams direction on how to interpret policies for accurate review.
Directs and mentors a high-performing team of MPPS policy clinical and coding subject-matter leaders, project managers and/or project coordinators.
Directs a portfolio of complex, cross-functional projects supporting MPPS initiatives throughout project lifecycles (intake, planning, execution, monitoring, closure).
Ensure projects are delivered on time, within scope, and aligned to business and regulatory objectives.
Directs adoption of standardized project management methodologies (e.g., Agile, Waterfall, hybrid).
Implements continuous improvement initiatives to enhance delivery efficiency and quality.
Develops and maintains tools, templates, and SOPs to support consistent execution.
Communicates with executive leadership as medical coding & policy expert.
Facilitates governance forums, decision-making bodies, and cross-functional working sessions.
Communicates program status, risks, and key decisions clearly to senior leadership & stakeholders.
Administers quality oversight of SAI initiatives, ensuring policies are performing financially and operationally as expected.
Establishes and tracks key performance indicators (KPIs) for project and program success.
Leads team of policy experts who support and provide expert testimony during regulatory investigations, state fair hearings, and CMS audits.
Implements proactive issue resolution and escalation strategies.
Ensures audit readiness and compliance with internal controls and regulatory requirements.
Deliver executive-level reporting on SAI progress, outcomes, and operational impact.