Senior Manager, Payment Integrity COE

CVS Health•Hartford, CT

About The Position

The Senior Manager, Payment Integrity COE Rework & Escalations provides centralized program leadership for intake, tracking, coordination, reporting, and resolution of rework and escalations across the Payment Integrity Center of Excellence. The role establishes an operating rhythm, provides end-to-end visibility into status and risk, and ensures owners, dependencies, decisions, and due dates are documented and actively managed. The position works across Payment Integrity, Claims, Clinical, Network, Product, Technology, Compliance, Legal, Finance, Operations, SIU, vendors, and other enterprise partners to move complex issues from intake through closure. The leader turns fragmented updates into concise, decision-ready reporting, identifies recurring drivers and control gaps, and supports prioritization of corrective actions to reduce avoidable rework and improve operational stability. The position also leads assigned employees or contractors supporting portfolio tracking, analysis, reporting, or coordination, and builds repeatable capabilities and inclusive practices focused on transparency, disciplined execution, continuous improvement, and professional growth. Key deliverables include a centralized rework and escalation tracker; recurring operational and executive portfolio reporting; governance calendars and meeting artifacts; root-cause and corrective-action documentation with solution validation; standard lifecycle practices for intake through closure; and leadership-ready summaries of portfolio health, constraints, and opportunities to reduce recurring rework.

Requirements

7–10 years of progressive experience in program management, project management, process improvement, audit, provider reimbursement, or analytics.
Demonstrated experience coordinating complex cross-functional initiatives with multiple owners, dependencies, and competing priorities.
Ability to build and maintain trackers, action plans, dashboards, scorecards, executive summaries, and governance materials.
Experience using data to identify trends, explain portfolio health, surface risk, and support prioritization and decision-making.
Excellent written, verbal, facilitation, organization, and presentation skills.
Ability to establish structure in ambiguous situations, work independently, follow through on commitments, and appropriately escalate barriers.
Proven ability to influence without direct authority and build productive relationships in a matrixed organization.
Working knowledge of healthcare claims, payment integrity, reimbursement, audit, recovery, or related operational processes.
Bachelor’s degree or equivalent combination of education and relevant experience.

Nice To Haves

Experience with Commercial, Medicare, Medicaid, Marketplace, or other healthcare payment models.
Experience leading rework reduction, escalation management, root-cause analysis, corrective action, operational governance, or continuous-improvement programs.
Advanced proficiency with Microsoft Excel, PowerPoint, Word, Teams, and SharePoint; experience with Power BI, Visio, Planner, or comparable workflow and reporting tools.
Experience coordinating vendor-related issues, service-level performance, implementation risks, or cross-enterprise handoffs.
Knowledge of Lean, Six Sigma, SIPOC, RACI, ADKAR, Agile, or other structured process, change, and project-management practices.
Professional certification such as CPC, CCS, CPMA, CFE, AHFI, PMP, Lean Six Sigma, or a related credential.

Responsibilities

Own the centralized portfolio of Payment Integrity rework items and escalations, managing intake, categorization, prioritization, status, aging, dependencies, risks, decisions, and closure evidence.
Maintain a consistent source of truth for active work, including business and action owners, target dates, status, next steps, and escalation paths.
Coordinate concurrent workstreams, follow up on commitments, remove barriers, and prevent unresolved items from becoming operational risks.
Establish criteria and working norms for intake, triage, prioritization, handoffs, escalation, closure, and post-implementation monitoring.
Lead structured working sessions with business and technical partners to clarify issues, scope, impact, root cause, interim controls, corrective actions, and decision needs.
Coordinate stakeholders and activities across functions, vendors, systems, and processes to resolve issues.
Identify stalled work, conflicting priorities, unclear ownership, resource constraints, and unresolved dependencies; elevate decision points with options and recommendations.
Support sensitive or high-impact escalations with disciplined documentation, neutral facilitation, and timely communication.
Develop and maintain dashboards, scorecards, portfolio summaries, aging reports, risk views, and leadership updates.
Define and report measures such as intake volume, backlog, aging, cycle time, on-time actions, closure rate, recurrence, and financial or operational impact.
Synthesize detailed updates into concise reporting that highlights progress, trends, exceptions, risks, decisions required, and accountable owners.
Document and consistently apply reporting definitions, data sources, status criteria, and calculation methods.
Partner with operational owners and subject matter experts to document root causes, contributing factors, failure points, and control gaps using practical process-improvement methods.
Track corrective and preventive actions through implementation, validation, and sustained closure.
Analyze rework and escalation patterns to identify recurring drivers, systemic issues, high-friction handoffs, and opportunities for standardization or automation.
Translate lessons learned into process, training, control, communication, governance, or technology recommendations.
Design and facilitate tiered governance for working teams, functional leaders, and executives, with agendas, pre-reads, decisions, actions, and follow-up.
Maintain decision logs, action registers, risk and issue logs, milestone plans, and escalation records with version control and auditability.
Develop standard templates, definitions, workflows, and job aids for the PI COE rework and escalation lifecycle.
Promote accountability through transparent reporting, timely follow-up, defined service expectations, and fact-based escalation.
Build partnerships with leaders, process owners, analysts, project teams, and external partners involved in rework prevention and escalation resolution.
Prepare executive summaries, briefing materials, talking points, and recommendations tailored to the audience and decision required.
Coordinate communication and readiness for process changes, including stakeholder alignment, documentation, training, and transition support.
Encourage a collaborative, no-blame approach focused on facts, accountability, sustainable fixes, and measurable outcomes.
Lead, coach, and develop assigned employees or contractors; set expectations, prioritize work, review deliverables, and build capabilities that improve quality, responsiveness, and stakeholder experience.
Create an inclusive environment that values transparency, disciplined execution, continuous improvement, and professional growth.