Position SummaryLead Director, MPPS Policy Consultation, directs medical, clinical, & payment policy SAI (Scorable Action Item) processes, leading teams to execute projects from initiation through completion. Collaborates cross-functionally as an expert policy advisor with clinical, coding, operations, compliance and technology teams to deliver value to the organization. Secures required resources and formal processes and tools to manage resources, budgets, risk, and changes. Assesses roadblocks to ensure on-time completion according to specifications and within budgeted costs. Collaborates as expert policy advisor with stakeholders (ie: Medical Economics, product lines, Network) to develop strategic plans for projects and programs delivering high-impact outcomes to improve policy performance, claim accuracy, and regulatory compliance. Prepares & presents SAI progress reports to stakeholders and senior management. Administers areas for continuous improvement in SAI lifecycle and ensures compliance, high performance standards, and quality outcomes.
Policy Development & Implementation- Directs research, authoring, evaluation, & implementation of medical, clinical & payment policies bringing new value to the organization
- Makes certain policies are driven by evidence-based practices and supported by federal & state regulations
- Aligns with PI COE and other internal and external stakeholders throughout implementation, establishing clear business requirements and coding architecture for accurate configuration and operational success
- Leverage data-driven insights to inform strategic decisions and improvements
- Provides operational review teams direction on how to interpret policies for accurate review
People, Program & Project Leadership- Directs and mentors a high-performing team of MPPS policy clinical and coding subject-matter leaders, project managers and/or project coordinators
- Directs a portfolio of complex, cross-functional projects supporting MPPS initiatives throughout project lifecycles (intake, planning, execution, monitoring, closure)
- Ensure projects are delivered on time, within scope, and aligned to business and regulatory objectives
- Directs adoption of standardized project management methodologies (e.g., Agile, Waterfall, hybrid)
- Implements continuous improvement initiatives to enhance delivery efficiency and quality
- Develops and maintains tools, templates, and SOPs to support consistent execution
Stakeholder Engagement, Governance & Transparency- Communicates with executive leadership as medical coding & policy expert
- Facilitates governance forums, decision-making bodies, and cross-functional working sessions
- Communicates program status, risks, and key decisions clearly to senior leadership & stakeholders
- Administers quality oversight of SAI initiatives, ensuring policies are performing financially and operationally as expected
- Establishes and tracks key performance indicators (KPIs) for project and program success
Regulatory Affairs & Compliance- Leads team of policy experts who support and provide expert testimony during regulatory investigations, state fair hearings, and CMS audits.
- Implements proactive issue resolution and escalation strategies
- Ensures audit readiness and compliance with internal controls and regulatory requirements
- Deliver executive-level reporting on SAI progress, outcomes, and operational impact
Can work from anywhere in the US
Required Qualifications- 10+ years of experience in project or program management
- 10+ years of experience within healthcare (health plan, payer, or related environment), with emphasis on medical policy, payment integrity and improvement of cost of care
- Strong understanding of Medicare and Medicaid regulations
- Demonstrated expertise leading cross-functional initiatives impacting operations, policy, or compliance
- Adept at execution and delivery (planning, delivering, & supporting)
- Advanced project/program management expertise across large-scale, cross-functional initiatives
- Mastery of problem-solving, prioritizing and decision-making skills in a fast-paced environment
- Mastery of growth mindset approach (agility with developing self and others)
Preferred Qualifications- Experience in medical policy, payment policy, claims operations, or utilization management
- Experience with Lean Six Sigma, process improvement, Agile and hybrid delivery models
- Experience supporting regulatory or audit-driven initiatives (e.g., CMS, HIPAA)
- Experience with SAI system implementations, configuration, or policy deployment initiatives
Education- Bachelor's degree in business administration, Healthcare Administration, Public Health, or related field required or equivalent experience
- Medical coding certification (ie: CPC, CCS, CPMA, RHIT) required or must obtain within 1 year of employment.
- Clinical licensure (ie: RN, LPN, PA) preferred
Pay RangeThe typical pay range for this role is:
$100,000.00 - $231,540.00
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: 08/06/2026
