Provides executive leadership for Medicaid Program Integrity and Regulatory Affairs across the enterprise, establishing strategy, governance, regulatory engagement, and operational oversight to ensure compliance, mitigate risk, protect program dollars, and support business growth. Serves as the organization's senior subject matter expert for Medicaid Payment Integrity, overseeing fraud, waste and abuse (FWA) prevention, payment accuracy, regulatory compliance, government agency engagement, and policy governance across the Medicaid business.Leads a team responsible for managing regulatory inquiries, audits, investigations, Requests for Information (RFIs), reporting obligations, and compliance activities involving state Medicaid agencies, Medicaid Fraud Control Units (MFCUs), CMS, and other regulatory bodies. Partners closely with Medicaid executive leadership to establish standardized operating practices, identify and mitigate regulatory risk, drive operational excellence, and advance strategic growth initiatives across multiple Medicaid markets.Key Responsibilities- Develop and execute enterprise-wide Program Integrity and Regulatory Affairs strategies that support Medicaid business objectives, regulatory compliance requirements, operational effectiveness, and long-term growth initiatives.
- Provide executive oversight of Medicaid Payment Integrity programs, including payment accuracy, overpayment recovery, fraud, waste and abuse prevention, provider oversight, auditing, monitoring, investigations, and compliance activities.
- Lead and develop a high-performing team responsible for managing all government agency requirements related to Medicaid Program Integrity and Payment Integrity programs.
- Serve as the executive liaison with state Medicaid agencies, Medicaid Fraud Control Units (MFCUs), CMS, auditors, regulators, and other governmental entities.
- Direct organizational responses to regulatory audits, investigations, corrective action plans, Requests for Information (RFIs), and state and federal reporting obligations.
- Monitor and interpret federal and state regulatory changes impacting Medicaid and Payment Integrity programs and develop strategies to ensure ongoing compliance, operational readiness, and business continuity.
- Partner with Compliance, Legal, Special Investigations Unit (SIU), Claims, Network, Operations, Finance, Government Affairs, and Medicaid market leadership to ensure enterprise alignment on Program Integrity priorities.
- Establish enterprise-wide policies, governance frameworks, controls, methodologies, and best practices that drive consistency, accountability, and compliance across Medicaid markets.
- Lead the identification, evaluation, and implementation of strategic opportunities to enhance Payment Integrity capabilities, improve payment accuracy, reduce financial risk, and support organizational growth.
- Oversee development and implementation of compliance monitoring programs, audits, and assessments designed to evaluate and improve Program Integrity effectiveness.
- Develop executive-level business cases and recommendations supporting program expansion, operational improvements, regulatory readiness, and strategic investments.
- Represent the organization in meetings, hearings, industry forums, and discussions with regulators, government officials, legislative bodies, and external stakeholders.
- Communicate regulatory risks, opportunities, emerging trends, and business impacts to executive leadership and support enterprise decision-making.
- Establish governance processes for documenting decisions, regulatory commitments, policy changes, and strategic growth initiatives across Medicaid markets.
- Develop and champion training, education, and knowledge-sharing programs that strengthen organizational understanding of Program Integrity requirements and best practices.
- Lead organizational transformation and process improvement initiatives that enhance effectiveness, scalability, compliance performance, and operational efficiency.
- Manage team performance through coaching, talent development, succession planning, performance management, and retention strategies.
Qualifications- 12+ years of progressive leadership experience in Medicaid Program Integrity, Payment Integrity, Compliance, Managed Care Operations, Healthcare Operations, or a related healthcare function.
- Deep expertise in Medicaid managed care regulations, state Medicaid contracts, CMS requirements, fraud, waste and abuse (FWA) programs, and Medicaid Program Integrity operations.
- Demonstrated leadership of enterprise-wide Program Integrity, Payment Integrity, Regulatory Affairs, Compliance, or operational functions within a complex healthcare organization.
- Proven experience serving as a primary executive liaison with state Medicaid agencies, CMS, Medicaid Fraud Control Units (MFCUs), auditors, regulators, and other governmental entities.
- Significant experience leading regulatory audits, investigations, corrective action plans, Requests for Information (RFIs), regulatory examinations, and government reporting activities.
- Demonstrated success developing and executing enterprise and multi-year strategic plans that align regulatory requirements, operational priorities, and business growth objectives.
- Strong knowledge of Payment Integrity operations claims payment accuracy, overpayment recovery methodologies, fraud prevention programs, provider oversight, auditing, and compliance monitoring.
- Proven ability to influence executive leadership and drive enterprise-wide decision-making within a highly matrixed organization.
- Demonstrated success leading large-scale transformational initiatives, organizational change efforts, and process improvement programs.
- Experience building, leading, and developing high-performing teams responsible for regulatory, operational, compliance, or Program Integrity functions.
- Exceptional executive communication, stakeholder management, negotiation, and relationship-building skills.
- Demonstrated ability to analyze complex regulatory, operational, and financial issues and translate findings into strategic business solutions.
- Bachelor's degree or equivalent
Pay RangeThe typical pay range for this role is:
$131,500.00 - $303,195.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program.
Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
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.
We anticipate the application window for this opening will close on: 08/10/2026
