Sr Manager Corporate Compliance-Special Needs Plans (Clinical)

CVS Health Corporation; United States; À distance; USD 83 000 - 183 000; Plein temps

Avantages offerts par ce poste

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Bonus eligibility and equity program

Résumé du poste

CVS Health is seeking a Sr. Manager Compliance to lead Medicare/Medicaid compliance programs within SNPs, navigating CMS rules and state requirements in a complex, regulated environment.

You will partner with senior business teams, oversee audits, risk assessments, external reviews, and regulatory inquiries, travel up to 10%, and help drive ethical, compliant outcomes across the organization.

Qualifications

• Extensive Medicare/Medicaid compliance knowledge including SNP Models of Care, Care Management and Quality Improvement Programs.
• Experience in validation, auditing, monitoring, root cause analysis and corrective action oversight.
• Outstanding time management and project management.
• Proficient in information systems usage.
• Strong ability to translate regulatory requirements for business stakeholders.
• Strong problem solving and decision-making skills in execution and delivery.
• Ability to collaborate effectively in matrixed environments.
• 7+ years in Medicare/Medi-Gov healthcare compliance or regulatory work.
• 2+ years of Project Management experience.

Responsabilités

• Serve as market compliance officer for assigned SNPs.
• Monitor CMS and state regulations and ensure program compliance and CVS Code of Conduct.
• Lead and implement an effective Compliance Program with risk assessment, auditing and corrective action oversight.
• Develop and manage compliance strategies and processes to prevent and mitigate risks.
• Maintain working knowledge of Medicare/Medicaid/state requirements for SNPs.
• Support regulatory inquiries and prepare strategic written responses.
• Lead external regulatory reviews and audits and coordinate corrective actions.
• Build relationships with internal and external stakeholders to influence compliant outcomes.

Connaissances

Medicare/Medicaid compliance

Regulatory analysis

Project management

Stakeholder communication

Auditing & monitoring

Risk assessment

Regulatory writing

Collaboration in matrixed environments

Travel readiness

Formation

Bachelor's degree or equivalent experience

Description du poste

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.

Position Summary

The Sr. Manager is an experienced/career level compliance position that applies compliance, regulatory, business, analytical and communication skills to support, manage and develop and execute Medicare and Medicaid compliance programs and processes that promote compliant and ethical behavior, meet regulatory obligations, and prevent, detect and mitigate compliance risks. The individual will work independently, as well as collaboratively, with internal senior level corporate compliance and business teams that operate Medicare Advantage in a highly complex regulatory environment and highly matrixed organization environment with a current focus on integrated and non-integrated special needs plans. The Sr. Manager Compliance maintains productive relationships and open lines of communication with internal and key external stakeholders to effectively communicate and influence compliant outcomes and ensure that processes are enhanced or implemented to effectively address compliance requirements.

Responsibilities

• Serve as market compliance officer for assigned Special Needs Plans (SNPs).
• Track, analyze, research, interpret, communicate and monitor applicable CMS and state regulations and government contract requirements to develop recommendations, direction, and escalation ensuring Aetna’s that implementation and integration of program requirements complies with federal and state specific program requirements and the CVS Code of Conduct.
• Lead and implement an effective Compliance Program as described in CMS Medicare Managed Care Manuals/regulations, applicable Medicaid rules and government contracts, including risk assessment, auditing and monitoring and corrective action oversight.
• Develop and manage compliance strategies, programs, and processes that promote compliant and ethical behavior, meet regulatory obligations, and prevent, detect, and mitigate compliance risks.
• Maintain in-depth working knowledge and expertise in Medicare, Medicaid and State requirements, regulations and contracts with a focus on supporting special needs plans.
• Support and/or facilitate multiple compliance and contract related communications, activities and interactions with regulators, including meeting with regulators on compliance with laws and regulations, developing or assisting in the development of appropriate and strategic written responses to compliance-related regulatory inquiries requiring an understanding of business processes and regulatory requirements and positive relationships with regulators.
• Leads and/or support numerous external regulatory review and audit activities, including the preparation for and management of external audits conducted by CMS and state Medicaid and related agencies or partners in conjunction with health plan leadership through final report and corrective action plan closure.
• Builds and maintains positive relationships with internal and external constituents at senior levels to drive decision-making and influence ethical and compliant outcomes.
• Monitor and audit as outlined in Medicare Compliance Work Plan and direct other projects as assigned to evaluate compliance, propose remediation where necessary and monitor implementation of corrective action.
• Utilize and maintain current information in systems unique to job functions, such as Microsoft products and compliance specific tools such as Archer Lead and support broader compliance initiatives and needs as assigned to ensure that effective compliance programs are achieved and maintained.

Required Qualifications

• Extensive knowledge of Medicare and Medicaid compliance programs and rules, including rules applying to special needs plans and CMS, NCQA and state rules and standards governing SNP Models of Care, Care Management and Quality Improvement Programs.
• Experience in validation, auditing and monitoring, root cause analysis and corrective action oversight.
• Outstanding time management and project management.
• Proficient in utilization of information systems.
• Mastery in complex regulatory rule analysis and clear communication of requirements to support business stakeholders.
• Mastery of problem solving and decision making skills dept at execution and delivery (planning, delivering, and supporting) skills.
• Adept at collaboration and teamwork in matrixed environments.
• 7+ years experience in Medicare or Medicare Advantage government healthcare program compliance or regulatory work.
• 2+ years of Project Management experience.
• Ability to travel up to 10%.
• Preferred Qualifications Prior clinical or operational experience enabling interpretation of assessments, claims, and clinical documentation (RN, LPN, SW or similar role/ background preferred).
• Experience administering or overseeing SNP MOC and external quality requirements and reviews.
• Education Bachelor's Degree OR equivalent experience required.

Pay Range

The typical pay range for this role is: $82,940.00 - $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

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

Application Deadline

We anticipate the application window for this opening will close on: 10/30/2026.

Legal Eligibility

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

Company Culture

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.