Sr Manager Corporate Compliance-Special Needs Plans (Clinical)

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. 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 include, but are not limited to: 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 In order to be successful in this role you must exhibit the following: - 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 Required Qualifications 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people 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 . We anticipate the application window for this opening will close on: 07/31/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.