Payment Integrity Rework & Escalations Lead

CVS Health

Phoenix (AZ)

On-site

USD 75,000 - 199,000

Full time

9 days ago

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Job summary

CVS Health is seeking a Senior Manager for Payment Integrity COE Rework & Escalations to lead cross-functional efforts across Payment Integrity, Claims, Clinical, and Technology. You will own the rework and escalation portfolio, drive clarity, and deliver decision-ready reporting for leadership.

The role requires 7–10 years in program management, strong governance, and data-driven decision making. This on-site position in Phoenix offers broad impact and opportunity to reduce rework and improve

Qualifications

7-10 years of progressive experience in program, project management, process improvement, audit, provider reimbursement, analytics.
Experience coordinating complex, cross-functional initiatives with multiple owners, dependencies, and competing priorities.
Strong ability to build trackers, action plans, dashboards, and governance materials.
Experience using data to identify trends, explain portfolio health, surface risk, and support prioritization.
Excellent written, verbal, facilitation, organization, and presentation skills.
Ability to establish structure in ambiguous situations, work independently, follow through on commitments, and escalate when needed.
Proven ability to influence without direct authority and build productive relationships in a matrixed organization.
Working knowledge of healthcare claims, payment integrity, reimbursement, audit, recovery, or related processes.

Responsibilities

Own the centralized portfolio of Payment Integrity rework items and escalations, including intake, categorization, prioritization, status management, aging, dependencies, risks, decisions, and closure evidence.
Maintain a consistent source of truth for active work, ensuring each item has a defined business owner, accountable action owner, target date, current status, next step, and escalation path.
Coordinate multiple concurrent workstreams and follow up on commitments to sustain momentum, remove barriers, and prevent unresolved items from becoming operational risks.
Establish criteria and working norms for intake, triage, prioritization, handoffs, escalation, closure, and post-implementation monitoring.
Lead structured working sessions with business and technical partners to clarify the issue, scope, impact, root cause, interim controls, corrective actions, and decision needs.
Connect the appropriate stakeholders across functional boundaries and coordinate activities when resolution requires multiple teams, vendors, systems, or processes.
Identify stalled work, conflicting priorities, unclear ownership, resource constraints, and unresolved dependencies; elevate decision points with clear options and recommendations.
Support sensitive or high-impact escalations with disciplined documentation, neutral facilitation, and timely communication.
Develop and maintain recurring dashboards, scorecards, portfolio summaries, aging reports, risk views, and leadership updates for rework and escalation activity.
Define meaningful measures for intake volume, backlog, aging, cycle time, on-time actions, closure rate, recurrence, financial or operational impact, and other agreed performance indicators.
Synthesize detailed updates into concise, decision-ready reporting that highlights progress, emerging trends, exceptions, risks, required decisions, and accountable owners.
Ensure reporting definitions, data sources, status criteria, and calculation methods are documented and applied consistently.
Partner with operational owners and subject matter experts to document root causes, contributing factors, failure points, and control gaps using practical process-improvement methods.
Track corrective and preventive actions through implementation, validation, and sustained closure rather than administrative completion alone.
Analyze patterns across rework and escalation activity to identify repeat drivers, systemic issues, high-friction handoffs, and opportunities for standardization or automation.
Translate lessons learned into process, training, control, communication, governance, or technology recommendations.
Design and facilitate a tiered governance cadence for working teams, functional leaders, and executive stakeholders, with clear agendas, pre-reads, decisions, actions, and follow-up.
Maintain decision logs, action registers, risk and issue logs, milestone plans, and escalation records with appropriate version control and auditability.
Develop standard templates, definitions, workflows, and job aids that improve consistency across the PI COE rework and escalation lifecycle.
Promote accountability through transparent reporting, timely follow-up, defined service expectations, and fact-based escalation.
Build trusted partnerships with leaders, process owners, analysts, project teams, and external partners involved in rework prevention and escalation resolution.
Prepare executive summaries, briefing materials, talking points, and recommendations tailored to the audience and decision required.
Coordinate communication and readiness activities for process changes resulting from corrective actions, including stakeholder alignment, documentation, training, and transition support.
Encourage a collaborative, no-blame approach that focuses on facts, accountability, sustainable fixes, and measurable outcomes.
Lead, coach, and develop assigned employees or contractors supporting portfolio tracking, analysis, reporting, or coordination.
Set clear expectations, prioritize work, review deliverables, and build repeatable capabilities that improve quality, responsiveness, and stakeholder experience.
Create an inclusive environment that values transparency, disciplined execution, continuous improvement, and professional growth.