Manager, Medicaid Provider Compliance

CVS Pharmacy; Dover (DE); On-site; USD 54,000 - 159,000; Full time

Benefits offered by this job

Comprehensive benefits package

Job summary

CVS Health in the United States seeks a strategic compliance leader to drive Medicaid provider compliance, audit readiness, and enterprise risk management. You will partner with executive leadership and external auditors to identify risks and establish best-in-class audit practices.

The role requires deep regulatory expertise, executive communication, and a track record leading high-impact initiatives that improve data integrity and controls across the organization.

Qualifications

• 7+ years of healthcare compliance, audit, or provider operations experience.
• Experience leading audits, CAPs, and regulatory responses.
• Strong analytical, risk assessment, and problem-solving skills.
• Knowledge of Medicaid regulations and provider compliance requirements.
• Excellent communication and stakeholder influence skills.
• Able to drive results across teams with competing priorities.
• Advanced Excel and data analysis proficiency.

Responsibilities

• Lead enterprise-wide provider compliance, audit preparedness, and regulatory initiatives that support organizational objectives and reduce compliance risk.
• Serve as the primary subject matter expert for complex provider compliance matters, providing strategic guidance to leadership and business partners.
• Develop and execute audit response and remediation strategies that address root causes, improve controls, and drive long-term compliance improvements.
• Influence cross-functional stakeholders and senior leadership to align priorities, resolve challenges, and implement effective compliance solutions.
• Assess emerging regulatory requirements, contractual obligations, and business risks; develop proactive strategies to ensure compliance and operational readiness.
• Lead complex, high-visibility projects spanning multiple departments, ensuring effective governance, accountability, risk management, and successful execution.
• Establish and maintain compliance monitoring frameworks, key performance indicators, and reporting mechanisms to measure compliance effectiveness and identify opportunities for improvement.
• Drive continuous improvement efforts through process redesign, automation opportunities, control optimization, and best practice implementation.
• Provide mentorship, guidance, and technical leadership to analysts and compliance professionals, fostering organizational capability and knowledge development.
• Build and maintain strong working relationships with regulators, auditors, health plans, provider relations teams, legal, compliance, and operational leadership.
• Present audit outcomes, compliance risks, trends, and recommendations to senior leadership and executive stakeholders.

Skills

Healthcare compliance

Project leadership

Audits & CAPs

Analytical skills

Medicaid regulations

Stakeholder influence

Cross-team delivery

Excel & data analysis

Education

Bachelor's degree

Master's degree preferred

Equivalent experience considered

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

About the Role

We are seeking a strategic compliance leader to drive Medicaid provider compliance, audit readiness, regulatory integrity, and enterprise risk management across the organization. This role serves as a senior subject matter expert responsible for shaping compliance strategy, leading complex cross-functional initiatives, influencing business decisions, and advancing sustainable solutions that strengthen regulatory performance and operational excellence. The successful candidate will partner with executive leadership, health plan stakeholders, compliance, legal, provider operations, and external auditors to proactively identify compliance risks, develop enterprise-wide mitigation strategies, and establish best-in-class audit and compliance practices. This position requires an influential leader who can navigate complex regulatory environments, drive organizational change, and deliver measurable business outcomes.

Position Summary

Provides enterprise leadership for Medicaid provider compliance, audit management, and regulatory oversight activities. Leads the development and execution of compliance strategies that support contractual, regulatory, and business objectives while promoting a culture of accountability, continuous improvement, and risk awareness. Serves as a recognized subject matter expert for provider compliance and audit readiness, driving initiatives that improve data integrity, strengthen internal controls, standardize processes, and enhance organizational performance. Partners across business areas to influence strategic decisions, manage emerging compliance risks, and ensure successful execution of high-impact compliance initiatives. The ideal candidate combines deep regulatory expertise, exceptional analytical capabilities, executive-level communication skills, and proven success leading complex initiatives that drive sustainable compliance outcomes.

Key Responsibilities

• Lead enterprise-wide provider compliance, audit preparedness, and regulatory initiatives that support organizational objectives and reduce compliance risk.
• Serve as the primary subject matter expert for complex provider compliance matters, providing strategic guidance to leadership and business partners.
• Develop and execute audit response and remediation strategies that address root causes, improve controls, and drive long-term compliance improvements.
• Influence cross-functional stakeholders and senior leadership to align priorities, resolve challenges, and implement effective compliance solutions.
• Assess emerging regulatory requirements, contractual obligations, and business risks; develop proactive strategies to ensure compliance and operational readiness.
• Lead complex, high-visibility projects spanning multiple departments, ensuring effective governance, accountability, risk management, and successful execution.
• Establish and maintain compliance monitoring frameworks, key performance indicators, and reporting mechanisms to measure compliance effectiveness and identify opportunities for improvement.
• Drive continuous improvement efforts through process redesign, automation opportunities, control optimization, and best practice implementation.
• Provide mentorship, guidance, and technical leadership to analysts and compliance professionals, fostering organizational capability and knowledge development.
• Build and maintain strong working relationships with regulators, auditors, health plans, provider relations teams, legal, compliance, and operational leadership.
• Present audit outcomes, compliance risks, trends, and recommendations to senior leadership and executive stakeholders.

Required Qualifications

• 7+ years of healthcare compliance, audit, or provider operations experience
• Proven ability to lead complex projects and compliance initiatives
• Experience managing audits, CAPs, and regulatory responses
• Strong analytical, risk assessment, and problem-solving skills
• Knowledge of Medicaid regulations and provider compliance requirements
• Excellent communication and stakeholder influence skills
• Ability to drive results across teams and manage competing priorities
• Advanced Excel and data analysis proficiency

Preferred Qualifications

• Experience with Medicaid provider compliance, provider data management, and healthcare network operations
• Proven success leading audits, compliance programs, and process improvement initiatives
• Experience developing compliance frameworks, controls, and governance programs
• Strong partnership experience with regulators, auditors, and senior leadership
• Knowledge of provider data systems, reporting tools, and compliance monitoring

Leadership Competencies

• Strategic Leadership & Business Acumen – Drives enterprise priorities, manages risk, and translates regulatory requirements into business solutions.
• Influence & Stakeholder Engagement – Builds trusted partnerships, communicates effectively with senior leaders, and influences outcomes across functions.
• Operational Excellence & Continuous Improvement – Uses data and compliance expertise to optimize processes, strengthen controls, and deliver sustainable results.

Education

• Bachelor's degree.
• Master's degree in Healthcare Administration, Business Administration, Public Health, Compliance, or related field preferred.
• Equivalent combination of education, specialized training, and relevant experience may be considered.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,300.00 - $159,120.00

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.

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Great benefits for great people

• 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: 09/01/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.