Senior Manager – Medical Policy, Program Solutions

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

📋 Description

• Formulate and implement strategies to identify, assess, prioritize, and promote opportunities for optimizing medical and payment policies.

• Utilize claims, appeals, coding, reimbursement, provider, and operational data to uncover trends, friction points, and areas for improvement.

• Review and enhance policies throughout the claims lifecycle, including both pre-payment and post-payment processes.

• Create evidence-based recommendations that consider policy intent, clinical and coding standards, provider experience, compliance, and the impact on business.

• Develop methodologies and performance metrics to progress opportunities from analysis to implementation and assessment.

• Offer strategic direction for experience optimization programs while maintaining a prioritized portfolio consistent with enterprise goals.

• Set up intake, prioritization, governance, and decision-making protocols.

• Collaborate with analytics and technology teams to generate reporting and insights.

• Assess outcomes and convert recurring trends into comprehensive improvement strategies.

• Lead cross-functional assessments and translate findings into recommendations, risks, trade-offs, and expected results.

• Persuade senior leaders and stakeholders throughout a complex organizational structure.

• Build partnerships and transitions across policy development, remediation, configuration, implementation, and operational teams.

• Mentor, coach, and develop team members.

⛳️ Requirements

• Over 5 years of experience in healthcare, medical or payment policy, payment integrity, coding, claims, appeals, healthcare analytics, provider experience, or similar healthcare roles.

• Required supervisory or formal leadership experience.

• Proven experience utilizing multiple data sources to identify trends, performance gaps, and optimization opportunities, translating insights into actionable recommendations.

• In-depth knowledge of healthcare reimbursement, claims processing, medical and/or payment policies, and coding concepts, including CPT, HCPCS, and ICD-10.

• Experience leading intricate, cross-functional initiatives from analysis and recommendation to implementation and evaluation.

• Capability to communicate complex findings, influence decision-making processes, and collaborate across a matrixed organization.

• Strong skills in strategic thinking, analytical problem-solving, communication, and stakeholder management.

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

• A relevant healthcare or coding credential, such as CPC, CCS, RHIT, or an equivalent credential, is required or must be obtained within one year of employment.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program.

• 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.