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Candidate may reside anywhere in US
Position Summary
The Senior Manager, Medical & Pre-Payment Policy Deviation Management is responsible for leading the review, governance, quality assurance, and operational oversight of Medical Policy and Pre-Payment Policy deviation requests. This role develops and maintains standardized review criteria, decision frameworks, and quality controls to ensure deviation requests are consistently evaluated, appropriately aligned to applicable medical and pre-payment policies, and supported by complete, audit-ready documentation.
The position serves as the subject matter expert for Medical Policy and Pre-Payment Policy exceptions, partnering with Product, Plan Sponsor, Provider Network, Clinical, Coding, Compliance, Legal, and Operational stakeholders to assess requests, determine policy applicability, evaluate business and regulatory impacts, and support informed decision-making. The Senior Manager is accountable for oversight of the Medical Policy Deviation Committee and ensure deviation determinations are accurate, compliant, operationally executable, and aligned with medical policy intent.
Medical Policy Deviation Governance
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Lead the governance framework for Medical Policy and Pre-Payment Policy deviation requests.
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Develop and maintain deviation review guidelines, approval criteria, decision standards, and escalation pathways.
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Ensure consistent application of medical policy intent, business rules, and governance requirements across all deviation requests.
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Maintain accountability for deviation request intake, review, disposition, and documentation processes.
Policy Review & Alignment
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Review Medical Policy and Pre-Payment Policy deviation requests for completeness, appropriateness, business justification, and operational feasibility.
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Identify and validate the appropriate medical, coding, reimbursement, and pre-payment policies applicable to each request.
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Ensure deviation recommendations align with policy intent, clinical guidelines, contractual obligations, and regulatory requirements.
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Evaluate requests involving multiple policy dependencies and provide policy interpretation and consultation to stakeholders
Deviation Committee Leadership
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Provide operational leadership and oversight of the Medical Policy Deviation Committee.
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Facilitate case reviews, stakeholder discussions, approvals, and escalation of complex or high-risk requests.
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Ensure committee decisions are documented, communicated, and maintained in accordance with governance standards.
Business Partnership & Stakeholder Collaboration
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Partner with Product, Plan Sponsor, Provider Network, Clinical, Medical Policy, Coding, Compliance, Legal, and Operational teams to evaluate deviation requests and associated impacts.
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Serve as the primary contact for policy deviation consultation and exception review processes.
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Build collaborative relationships that support effective governance, transparency, and timely decision-making.
Quality Assurance & Compliance
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Develop and oversee a quality assurance program for Medical Policy and Pre-Payment Policy deviation activities.
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Conduct quality reviews to validate policy alignment, decision accuracy, documentation integrity, and governance compliance.
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Perform periodic audits and implementation reviews to verify approved deviations are operationalized accurately.
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Ensure deviation records, rationale, approvals, and implementation evidence are maintained in an audit-ready manner.
Reporting & Continuous Improvement
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Develop reporting and performance metrics related to deviation volumes, turnaround times, approval outcomes, and quality performance.
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Analyze deviation trends, appeals, quality findings, and recurring exception requests to identify opportunities for policy clarification and process improvement.
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Lead initiatives focused on improving review consistency, reducing rework, strengthening controls, and enhancing governance effectiveness.
Required Qualifications
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7+ years of experience in Medical Policy, Pre-Payment Policy, Payment Integrity, Claims Operations, Utilization Management, Healthcare Compliance, or related healthcare functions
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5+ years of leadership experience managing programs, teams, or governance functions
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Demonstrated experience interpreting medical and reimbursement policies and translating policy requirements into operational decision-making
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Experience supporting policy review committees, governance forums, or exception management processes
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Experience performing quality assurance, auditing, compliance reviews, or operational oversight activities
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Medical Policy and Pre-Payment Policy expertise preferred
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Healthcare reimbursement and coding knowledge
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Strong understanding of claims processing and payment integrity operations.
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Policy interpretation and analytical decision-making
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Root cause analysis and problem-solving
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Quality assurance and audit management
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Executive communication and stakeholder management
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Process improvement and governance oversight
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Strong facilitation, negotiation, and organizational skills
Preferred Qualifications
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Experience supporting Medical Policy and Payment Integrity programs.
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Experience working with Commercial, Medicare, and Medicaid products.
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Experience leading deviation review, policy governance, or exception management committees.
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Experience developing quality management, audit, or compliance programs.
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Experience designing operational dashboards, KPIs, and executive reporting.
Education
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Bachelor's degree in Healthcare Administration, Nursing, or related field; relevant healthcare industry experience may be considered.
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Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or equivalent coding certification required.
Pay Range
The typical pay range for this role is:
$67,900.00 - $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: 08/25/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
