Lead Director, Medical Policy Optimization and Customization
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Job Description
CVS Health enterprise policy compliance leader optimizing medical policy governance and regulatory adherence. Driving quality, risk reduction, executive reporting, and cross-functional change.
Responsibilities:
- Provide strategic leadership for enterprise policy compliance and optimization functions
- Lead enterprise oversight of policy adherence to regulatory, contractual, and organizational requirements
- Establish and maintain governance frameworks across all lines of business
- Monitor regulatory and industry changes, assess business impact, and direct required policy updates
- Ensure policies align with applicable federal, state, and internal standards
- Direct policy deviation activities arising from audits, assessments, regulatory findings, and business decisions
- Develop and execute strategies to enhance policy management processes and reduce compliance risk
- Drive continuous improvement across policy development, review, approval, and quality oversight
- Identify opportunities to simplify policy structures while maintaining compliance and business objectives
- Establish metrics and performance indicators to evaluate policy effectiveness
- Ensure effective controls support compliance and business integrity
- Partner with business, legal, compliance, clinical, operational, and technology stakeholders
- Facilitate executive-level decisions on policy interpretation, implementation, and risk mitigation
- Lead cross-functional teams for policy initiatives, regulatory readiness, deviation management, and process improvement
- Develop executive-level reporting and dashboards on policy performance, effectiveness, risks, and opportunities
- Analyze trends, audit findings, and operational data to inform strategic decisions
- Present recommendations and outcomes to senior leadership and governance committees
Requirements:
- 10+ years of progressive leadership experience in policy governance, compliance, healthcare operations, payment integrity, medical policy, utilization management, risk management, or related functions
- 7+ years of people leadership experience managing professional staff and cross-functional teams
- Experience leading enterprise-wide policy programs and governance frameworks
- Experience presenting to executive leadership and governance committees
- Ability to align policy governance with organizational goals and business strategy
- Ability to influence without authority across matrixed organizations
- Strong executive presence and communication skills
- Ability to lead organizational change and drive adoption of new processes
- Bachelor’s degree in healthcare administration, business, public health, or related field, or equivalent experience
- Relevant certification and/or current license required, such as CPC, RHIT, CCS, or equivalent healthcare/coding credential, or must obtain credential/certification within one year of employment
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Award target in the company’s equity award program
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
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