[Hiring] Senior Manager Medical Policy & Program Solutions @CVS Health

Role Description

The Senior Manager, Medical Policy & Program Solutions (MPPS) Experience Optimization leads data-driven strategies to improve medical and payment policy effectiveness and the provider experience. This role leverages claims, appeals, coding, reimbursement, provider experience, and operational insights to identify optimization opportunities, translate findings into actionable recommendations, and lead cross-functional initiatives that reduce unnecessary administrative burden and drive measurable improvement.

• Policy and Experience Optimization
  • Develop and execute strategies to identify, evaluate, prioritize, and advance medical and payment policy optimization opportunities.
  • Leverage claims, appeals, coding, reimbursement, provider, and operational data to identify trends, friction points, and opportunities for improvement.
  • Evaluate and modernize policies to improve clarity, consistency, effectiveness, and applicability across the claims lifecycle, including both pre-payment and post-payment use.
  • Develop evidence-based recommendations that balance policy intent, clinical and coding standards, provider experience, compliance, and business impact.
  • Establish consistent approaches and performance measures to advance optimization opportunities from analysis through implementation and measurement.
• Experience Optimization Program Leadership
  • Provide strategic leadership for experience optimization programs and maintain a prioritized portfolio of opportunities aligned with enterprise objectives.
  • Develop proactive, data-driven approaches to identify emerging and systemic opportunities for policy and process improvement.
  • Establish effective intake, prioritization, governance, and decision-making practices for optimization initiatives.
  • Partner with analytics and technology teams to develop reporting and insights that strengthen visibility into policy performance and outcomes.
  • Establish success measures, evaluate results, and translate recurring trends into broader improvement strategies.
• Cross-Functional and Strategic Leadership
  • Partner across medical policy, clinical, coding, payment integrity, claims, appeals, provider, compliance, operations, analytics, technology, and other key functions.
  • Lead cross-functional evaluation of complex policy opportunities and translate findings into clear recommendations, risks, tradeoffs, and expected outcomes.
  • Influence senior leaders and stakeholders across a matrixed organization to advance policy optimization decisions and initiatives.
  • Establish effective partnerships and handoffs across policy development, remediation, configuration, implementation, and operational teams.
  • Promote data-driven decision-making and continuous improvement while providing leadership, coaching, and development to team members.

Qualifications

• 5+ years of experience in healthcare, medical or payment policy, payment integrity, coding, claims, appeals, healthcare analytics, provider experience, or related healthcare functions.
• Supervisory or formal people-leadership experience required.
• Demonstrated experience using multiple data sources to identify trends, performance gaps, and optimization opportunities and translate findings into actionable recommendations.
• Strong knowledge of healthcare reimbursement, claims processing, medical and/or payment policy, and coding concepts, including CPT, HCPCS, and ICD-10.
• Experience leading complex, cross-functional initiatives from analysis and recommendation through implementation and measurement.
• Demonstrated ability to communicate complex findings, influence decision-making, and collaborate effectively across a matrixed organization.
• Strong strategic thinking, analytical problem-solving, communication, and stakeholder-management skills.

Requirements

• Experience in policy optimization, payment integrity, provider experience, appeals, reimbursement strategy, or medical policy.
• Experience analyzing claims, denials, appeals, overturns, utilization, reimbursement, or provider-related data.
• Experience with payment policy, E&M coding, claim-editing concepts, or complex reimbursement methodologies.
• Experience developing performance measures, dashboards, or monitoring frameworks to evaluate policy or program effectiveness.

Education

• Bachelor’s degree in healthcare administration, business, public health, health informatics, nursing, analytics, or a related field, or equivalent professional experience.
• Relevant healthcare or coding credential, such as CPC, CCS, RHIT, or an equivalent credential, required or must be obtained within one year of employment.

Location

Candidate may reside anywhere in the United States.

Pay Range

The typical pay range for this role is: $67,900.00 - $182,549.00. 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.

Benefits

• Comprehensive and competitive mix of pay and benefits.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.