Senior Manager, Medicare Product Operations (NCOD)

CVS Health•Hartford, CT

12d

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 The Senior Manager, Medicare Product Operations (NCOD) is responsible for providing leadership, operational oversight, and people management for the Non-Clinical Organization Determination (NCOD) team. This leader is accountable for ensuring accurate, timely, compliant, and member-centered coverage determinations while maintaining adherence to CMS regulations, and internal policies. The role oversees a team of managers and analysts responsible for evaluating member requests, issuing organization determinations, maintaining documentation, and supporting appeals- and grievance-related activities. This position serves as a key operational leader, driving quality, compliance, performance, process optimization, workforce development, and cross-functional collaboration. The Senior Manager partners with Compliance, Product, Appeals, Grievances, Eligibility, Technology, and vendor partners to ensure operational excellence and a best-in-class member experience.

Requirements

7+ years of Medicare Advantage, healthcare operations, compliance, appeals, grievances, organization determinations, supplemental benefits, claims, or related experience.
3+ years of leadership experience managing teams.
Strong knowledge of Medicare Advantage regulations, CMS guidance, organization determinations, appeals, grievances, and supplemental benefit administration.
Experience translating regulation requirements into operational processes and controls.
Advanced organizational and prioritization skills with the ability to manage multiple competing priorities.
Proficiency in Microsoft Office Suite and operational reporting tools.
Bachelor’s Degree or equivalent experience.

Nice To Haves

Master’s degree in Business, Healthcare Administration, Public Health, Operations, or related field.
Experience leading Medicare Advantage organization determination, appeals, compliance, or supplemental benefit operations.
Experience supporting audits, regulatory examinations, or corrective action programs.

Responsibilities

Provides oversight for the NCOD operation, ensuring alignment with organizational goals, regulatory requirements, and member experience objectives.
Establishes operational strategies, and performance standards that support long-term scalability and sustainability.
Leads implementation of new NCOD workflows, benefit offerings, regulatory requirements, operational enhancements, and system improvements.
Serves as a subject matter expert and operational consultant for NCODs.
Oversees end-to-end NCOD operations, including intake, review, determination, documentation and communication.
Ensures compliance with established turnaround times, and regulatory requirements.
Monitors workload distribution, staffing needs, productivity trends, and inventory management.
Leads operational readiness planning for benefit, process, policy, and technology changes.
Directly supervises NCOD managers and analysts.
Establishes clear performance expectations and accountability measures to drive individual and team success.
Coaches, mentors, and develops staff through ongoing feedback, performance management, career development planning, and succession planning.
Creates an inclusive, collaborative, and high-performing culture focused on accountability, quality, service, and continuous improvement.
Leads workforce engagement initiatives and promotes a positive employee experience through recognition and development.
Interviews, hires, develops talent, provides guidance and coaching, and foster a high-performance culture.
Oversees ongoing training to ensure all team members are fully versed and compliant within their respective roles.
Ensures adherence to CMS regulations, internal policies, audit standards, and organizational determination guidelines.
Oversees and participates in quality assurance programs, audit activities, and calibration initiatives.
Maintains oversight of documentation standards to ensure decisions are accurate, complete, defensible, and audit-ready.
Partners with Compliance and Operational Integrity teams to assess regulatory changes and implement operational impacts.
Identifies and mitigates operational, compliance, and regulatory risks.
Establishes and monitors key performance indicators (KPIs), operational dashboards, quality metrics, and service-level measures.
Analyzes operational data to identify trends, root causes, risks, and opportunities for improvement.
Presents operational performance updates, recommendations, and strategic insights to senior leadership.
Utilizes data-driven decision-making to improve quality, efficiency, compliance, and member outcomes.
Leads continuous improvement initiatives focused on operational efficiency, quality outcomes, member satisfaction, and regulatory compliance.
Develops and enhances workflows, standard operating procedures, training materials, and operational controls.
Identifies workflow optimization strategies, and technology enhancements.
Partners with Product, Compliance, Appeals, Grievances, Eligibility, Technology, Vendor Management, customer service, and other stakeholders to resolve issues and improve performance.
Builds strong partnerships across the organization to ensure alignment and successful execution of strategic initiatives.
Supports enterprise projects, implementations, audits, and regulatory readiness activities.