Lead Director, Medical Policy Optimization and Customization

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Provide strategic direction for enterprise policy compliance and optimization initiatives.

• Oversee enterprise adherence to regulatory, contractual, and organizational policies.

• Create and uphold governance frameworks across all business divisions.

• Track changes in regulations and industry standards, evaluate their impact on the business, and lead necessary policy modifications.

• Ensure policies are in alignment with relevant federal, state, and internal regulations.

• Manage policy deviations that arise from audits, assessments, regulatory findings, and business decisions.

• Formulate and implement strategies to improve policy management processes and minimize compliance risks.

• Promote continuous enhancement in policy development, review, approval, and quality supervision.

• Identify opportunities to streamline policy structures while ensuring compliance and achieving business goals.

• Establish metrics and performance indicators to assess the effectiveness of policies.

• Ensure robust controls are in place to support compliance and uphold business integrity.

• Collaborate with business, legal, compliance, clinical, operational, and technology stakeholders.

• Guide executive-level decisions regarding policy interpretation, implementation, and risk management.

• Lead cross-functional teams on policy initiatives, regulatory preparedness, deviation management, and process enhancements.

• Develop executive-level reports and dashboards reflecting policy performance, effectiveness, risks, and opportunities.

• Analyze trends, audit results, and operational data to guide strategic decision-making.

• Present findings and recommendations 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 fields.

• 7+ years of experience in leading teams and managing professional staff across various functions.

• Proven experience in directing enterprise-wide policy programs and governance structures.

• Experience presenting to executive leadership and governance committees.

• Capability to align policy governance with organizational objectives and business strategies.

• Ability to influence across matrixed organizations without direct authority.

• Strong executive presence coupled with excellent communication skills.

• Proficient in leading organizational change and facilitating the adoption of new processes.

• Bachelor’s degree in healthcare administration, business, public health, or a related field, or equivalent experience.

• Relevant certification and/or current license required, such as CPC, RHIT, CCS, or an equivalent healthcare/coding credential, or the obligation to obtain the credential/certification within one year of employment.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Target award in the company’s equity award program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.