Manager, Medicaid Provider Compliance

Strategic Compliance Leader

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.

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.

Position Summary

Provides enterprise leadership for Medicaid provider compliance, audit management, and regulatory oversight activities. Leads the development and execution of compliance strategies that support contractual, regulatory, and business objectives while promoting a culture of accountability, continuous improvement, and risk awareness. Serves as a recognized subject matter expert for provider compliance and audit readiness, driving initiatives that improve data integrity, strengthen internal controls, standardize processes, and enhance organizational performance. Partners across business areas to influence strategic decisions, manage emerging compliance risks, and ensure successful execution of high-impact compliance initiatives. The ideal candidate combines deep regulatory expertise, exceptional analytical capabilities, executive-level communication skills, and proven success leading complex initiatives that drive sustainable compliance outcomes.

Key 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.

Required Qualifications

• 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

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.

Education

• 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.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: $54,300.00 - $159,120.00

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.