Senior Manager, Medicare Compliance - FDR Oversight Program

CVS Health • Hartford, CT

3d

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: As a Senior Manager of Medicare Compliance - FDR Oversight Program, you are an experienced, career level compliance professional responsible for the end-to-end execution and ongoing effectiveness of Medicare First Tier, Downstream, and Related (FDR) compliance oversight. This role will allow you to apply advanced regulatory, analytical, and communication skills to prevent, detect, and mitigate compliance risks while promoting ethical business practices in alignment with CMS requirements. In this role, you will independently lead compliance initiatives across delegated functions within a complex, matrixed Medicare Advantage environment. You’ll operate with a high degree of autonomy, exercising independent judgment in risk assessment, issue escalation, and oversight of corrective action plans. Partnering closely with Compliance peers and key business stakeholders, you will assess program effectiveness, proactively address emerging risks, and drive continuous improvement. To be successful in this role, you will need: Strong knowledge of Medicare compliance requirements, including CMS Organization Determination, Appeals and Grievances (ODAG). Ability to independently assess risk and recommend effective remediation using analytical and critical thinking skills. Experience leading auditing, monitoring, validation, and corrective action oversight activities. Clear, effective communication with stakeholders at all levels, including senior leadership. Strong execution, prioritization, and time management skills in a fast paced, matrixed environment. Comfort influencing outcomes and driving change without direct authority.

Requirements

• 7+ years of experience in healthcare, or Medicare Advantage program compliance or regulatory work
• 2+ years of experience independently leading complex compliance, risk, or regulatory initiatives
• Excellent written and verbal communication skills with strong analytical capabilities
• Ability to travel up to 10% (including plane)

Nice To Haves

• Prior clinical or operational experience enabling interpretation of medical records, treatment decisions, and clinical documentation (RN, LPN, or similar clinical role/ background preferred)
• Experience administering or overseeing FDR requirements outlined in CMS Compliance Program Guidelines (Chapters 9 and 21)
• Experience supporting CMS Organization Determination, Appeals and Grievances (ODAG) reviews

Responsibilities

• Execute the Medicare FDR Oversight Program, with primary responsibility for oversight of Organization Determination, Appeals and Grievances (ODAG) delegated functions.
• Provide compliance and operational oversight of delegated organization determination functions, applying clinical knowledge and judgment to assess medical management practices, regulatory adherence, and risk mitigation effectiveness.
• Own and execute auditing, monitoring, validation, and corrective action plan (CAP) oversight activities aligned within the Medicare Compliance Work Plan.
• Identify, prioritize, and escalate compliance risks; conduct root cause analysis; and support timely, sustainable remediation with internal and external partners.
• Serve as a subject matter expert on Medicare FDR oversight, maintaining current knowledge of CMS guidance, HPMS memos, and contractual requirements.
• Partner with internal stakeholders and delegated entities to strengthen compliance controls and promote consistent, compliant outcomes.
• Utilize compliance tools and systems, including Medicare eGRC platforms (e.g., Archer) and Microsoft applications, to support oversight, documentation, monitoring, and reporting.
• Support broader Medicare Compliance initiatives and projects as assigned.

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Number of Employees: 5,001-10,000 employees