MPPS Policy Deviations Senior Manager

CVS Health•Hartford, CT

3d•$67,900 - $182,549•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. Candidate may reside anywhere in US Position Summary The Senior Manager, Medical & Pre-Payment Policy Deviation Management is responsible for leading the review, governance, quality assurance, and operational oversight of Medical Policy and Pre-Payment Policy deviation requests. This role develops and maintains standardized review criteria, decision frameworks, and quality controls to ensure deviation requests are consistently evaluated, appropriately aligned to applicable medical and pre-payment policies, and supported by complete, audit-ready documentation. The position serves as the subject matter expert for Medical Policy and Pre-Payment Policy exceptions, partnering with Product, Plan Sponsor, Provider Network, Clinical, Coding, Compliance, Legal, and Operational stakeholders to assess requests, determine policy applicability, evaluate business and regulatory impacts, and support informed decision-making. The Senior Manager is accountable for oversight of the Medical Policy Deviation Committee and ensure deviation determinations are accurate, compliant, operationally executable, and aligned with medical policy intent.

Requirements

7+ years of experience in Medical Policy, Pre-Payment Policy, Payment Integrity, Claims Operations, Utilization Management, Healthcare Compliance, or related healthcare functions
5+ years of leadership experience managing programs, teams, or governance functions
Demonstrated experience interpreting medical and reimbursement policies and translating policy requirements into operational decision-making
Experience supporting policy review committees, governance forums, or exception management processes
Experience performing quality assurance, auditing, compliance reviews, or operational oversight activities
Medical Policy and Pre-Payment Policy expertise preferred
Healthcare reimbursement and coding knowledge
Strong understanding of claims processing and payment integrity operations.
Policy interpretation and analytical decision-making
Root cause analysis and problem-solving
Quality assurance and audit management
Executive communication and stakeholder management
Process improvement and governance oversight
Strong facilitation, negotiation, and organizational skills
Bachelor's degree in Healthcare Administration, Nursing, or related field; relevant healthcare industry experience may be considered.
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or equivalent coding certification required.

Nice To Haves

Experience supporting Medical Policy and Payment Integrity programs.
Experience working with Commercial, Medicare, and Medicaid products.
Experience leading deviation review, policy governance, or exception management committees.
Experience developing quality management, audit, or compliance programs.
Experience designing operational dashboards, KPIs, and executive reporting.

Responsibilities

Lead the governance framework for Medical Policy and Pre-Payment Policy deviation requests.
Develop and maintain deviation review guidelines, approval criteria, decision standards, and escalation pathways.
Ensure consistent application of medical policy intent, business rules, and governance requirements across all deviation requests.
Maintain accountability for deviation request intake, review, disposition, and documentation processes.
Review Medical Policy and Pre-Payment Policy deviation requests for completeness, appropriateness, business justification, and operational feasibility.
Identify and validate the appropriate medical, coding, reimbursement, and pre-payment policies applicable to each request.
Ensure deviation recommendations align with policy intent, clinical guidelines, contractual obligations, and regulatory requirements.
Evaluate requests involving multiple policy dependencies and provide policy interpretation and consultation to stakeholders
Provide operational leadership and oversight of the Medical Policy Deviation Committee.
Facilitate case reviews, stakeholder discussions, approvals, and escalation of complex or high-risk requests.
Ensure committee decisions are documented, communicated, and maintained in accordance with governance standards.
Partner with Product, Plan Sponsor, Provider Network, Clinical, Medical Policy, Coding, Compliance, Legal, and Operational teams to evaluate deviation requests and associated impacts.
Serve as the primary contact for policy deviation consultation and exception review processes.
Build collaborative relationships that support effective governance, transparency, and timely decision-making.
Develop and oversee a quality assurance program for Medical Policy and Pre-Payment Policy deviation activities.
Conduct quality reviews to validate policy alignment, decision accuracy, documentation integrity, and governance compliance.
Perform periodic audits and implementation reviews to verify approved deviations are operationalized accurately.
Ensure deviation records, rationale, approvals, and implementation evidence are maintained in an audit-ready manner.
Develop reporting and performance metrics related to deviation volumes, turnaround times, approval outcomes, and quality performance.
Analyze deviation trends, appeals, quality findings, and recurring exception requests to identify opportunities for policy clarification and process improvement.
Lead initiatives focused on improving review consistency, reducing rework, strengthening controls, and enhancing governance effectiveness.