Manager, Medicaid Provider Compliance

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.

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.

Requirements

• 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

Qualifications

• 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

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.

Pay

The typical pay range for this role is $54,300.00 - $159,120.00. This pay range represents the 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.

Benefits

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
• Other resources, based on eligibility

Schedule

• Full time
• 40 anticipated weekly hours