Senior Manager Medical Policy & Program Solutions MPPS

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.

The Senior Manager, Medical Policy & Program Solutions (MPPS) Experience Optimization leads data-driven strategies to improve medical and payment policy effectiveness and the provider experience. This role leverages claims, appeals, coding, reimbursement, provider experience, and operational insights to identify optimization opportunities, translate findings into actionable recommendations, and lead cross-functional initiatives that reduce unnecessary administrative burden and drive measurable improvement.

 

Policy and Experience Optimization

• Develop and execute strategies to identify, evaluate, prioritize, and advance medical and payment policy optimization opportunities.
• Leverage claims, appeals, coding, reimbursement, provider, and operational data to identify trends, friction points, and opportunities for improvement.
• Evaluate and modernize policies to improve clarity, consistency, effectiveness, and applicability across the claims lifecycle, including both pre-payment and post-payment use.
• Develop evidence-based recommendations that balance policy intent, clinical and coding standards, provider experience, compliance, and business impact.
• Establish consistent approaches and performance measures to advance optimization opportunities from analysis through implementation and measurement.

Experience Optimization Program Leadership

• Provide strategic leadership for experience optimization programs and maintain a prioritized portfolio of opportunities aligned with enterprise objectives.
• Develop proactive, data-driven approaches to identify emerging and systemic opportunities for policy and process improvement.
• Establish effective intake, prioritization, governance, and decision-making practices for optimization initiatives.
• Partner with analytics and technology teams to develop reporting and insights that strengthen visibility into policy performance and outcomes.
• Establish success measures, evaluate results, and translate recurring trends into broader improvement strategies.

Cross-Functional and Strategic Leadership

• Partner across medical policy, clinical, coding, payment integrity, claims, appeals, provider, compliance, operations, analytics, technology, and other key functions.
• Lead cross-functional evaluation of complex policy opportunities and translate findings into clear recommendations, risks, tradeoffs, and expected outcomes.
• Influence senior leaders and stakeholders across a matrixed organization to advance policy optimization decisions and initiatives.
• Establish effective partnerships and handoffs across policy development, remediation, configuration, implementation, and operational teams.
• Promote data-driven decision-making and continuous improvement while providing leadership, coaching, and development to team members.

 

Required Qualifications

• 5+ years of experience in healthcare, medical or payment policy, payment integrity, coding, claims, appeals, healthcare analytics, provider experience, or related healthcare functions.
• Supervisory or formal people-leadership experience required.
• Demonstrated experience using multiple data sources to identify trends, performance gaps, and optimization opportunities and translate findings into actionable recommendations.
• Strong knowledge of healthcare reimbursement, claims processing, medical and/or payment policy, and coding concepts, including CPT, HCPCS, and ICD-10.
• Experience leading complex, cross-functional initiatives from analysis and recommendation through implementation and measurement.
• Demonstrated ability to communicate complex findings, influence decision-making, and collaborate effectively across a matrixed organization.
• Strong strategic thinking, analytical problem-solving, communication, and stakeholder-management skills.

Preferred Qualifications

• Experience in policy optimization, payment integrity, provider experience, appeals, reimbursement strategy, or medical policy.
• Experience analyzing claims, denials, appeals, overturns, utilization, reimbursement, or provider-related data.
• Experience with payment policy, E&M coding, claim-editing concepts, or complex reimbursement methodologies.
• Experience developing performance measures, dashboards, or monitoring frameworks to evaluate policy or program effectiveness.

Education

Bachelor’s degree in healthcare administration, business, public health, health informatics, nursing, analytics, or a related field, or equivalent professional experience.

Relevant healthcare or coding credential, such as CPC, CCS, RHIT, or an equivalent credential, required or must be obtained within one year of employment.

Location

Candidate may reside anywhere in the United States.

 

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: 10/13/2026

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