Lead Director Medical Policy Optimization and Customization

About the role

Lead Director, MPPS Compliance & Policy Optimization provides strategic leadership for enterprise policy compliance and optimization functions, ensuring regulatory adherence, effective governance, quality excellence, and continuous improvement while minimizing risk and enabling business objectives through collaborative stakeholder engagement and data-driven decision-making. This role is not operational and does not include vendor oversight.

Responsibilities

• Policy Governance & Compliance: Lead enterprise oversight of policy adherence to regulatory, contractual, and organizational requirements. Establish and maintain governance frameworks that promote consistency, accountability, and compliance across all lines of business. Monitor regulatory and industry changes, assess business impact, and direct implementation of required policy updates. Ensure policies are aligned with applicable federal, state, and internal standards. Direct policy deviation activities resulting from audits, assessments, regulatory findings, and business decisions.
• Policy Quality Assurance & Optimization: Develop and execute strategies to enhance policy management processes, improve policy effectiveness, and reduce compliance risk. Drive continuous improvement initiatives that streamline policy development, review, approval, and quality oversight activities. Identify opportunities to simplify policy structures while maintaining compliance and business objectives. Establish metrics and performance indicators to evaluate policy effectiveness and drive optimization efforts. Ensure effective controls are in place to support compliance and business integrity.
• Cross-Functional Leadership: Partner with business, legal, compliance, clinical, operational, and technology stakeholders to ensure policy alignment and execution. Facilitate executive-level decision-making regarding policy interpretation, implementation, and risk mitigation strategies. Lead cross-functional teams responsible for policy initiatives, regulatory readiness, deviation management, and process improvement efforts.
• Performance Management & Reporting: Develop executive-level reporting and dashboards to communicate policy performance, policy effectiveness, risks, and opportunities. Analyze trends, audit findings, and operational data to inform strategic decisions and improvement initiatives. Present recommendations and outcomes to senior leadership and governance committees.

Required Qualifications

• 10+ years of progressive leadership experience in policy governance, compliance, healthcare operations, payment integrity, medical policy, utilization management, risk management, or related functions
• 7+ years people leadership experience managing professional staff & cross-functional teams
• Demonstrated experience leading enterprise-wide policy programs and governance frameworks
• Experience presenting to executive leadership and governance committees
• Strategic thinker with the ability to align policy governance with organizational goals and business strategy
• Proven ability to influence without authority across matrixed organizations
• Strong executive presence and communication skills
• Demonstrated ability to lead organizational change and drive adoption of new processes

Education & Certification

• Bachelor's degree in healthcare administration, business, public health, or related field, or equivalent experience
• Relevant certification and/or current license required (i.e. CPC, RHIT, CCS, or equivalent healthcare/coding credential) or must obtain credential/certification within one year of employment

Pay

• Typical pay range: $100,000.00 - $231,540.00 (base annual full-time salary for all positions in the job grade; actual base salary offer depends on experience, education, geography, and other relevant factors)
• Eligible for CVS Health bonus, commission, or short-term incentive program in addition to base pay
• Includes an award target in the company's equity award program

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources based on eligibility