Governance Risk Compliance Manager Jobs in Springfield, MA

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Position Summary
The Medicare appeals team is seeking a self-motivated and detail oriented Sr, Manager, Business compliance to join our team.. This role will ensure operational alignment with CMS regulations, manage responses to CMS inquiries, and lead readiness efforts for internal and external audit activities for the Medicare Part C and Fast Track Appeals teams. This position will work in close partnership with Medicare Compliance, Legal, Medicare Operations Integrity, and the Quality & Audit teams to ensure that all appeals processes are compliant, auditable, and responsive to regulatory expectations. The role requires a strong understanding of Medicare regulations, excellent communication skills, and the ability to manage complex issues and risks cross-functionally.

• Monitor and interpret new and evolving regulatory requirements and standards, ensuring the organization's processes and practices remain compliant.
• Function as a liaison with CMS representatives, external contractors, legal counsel, and internal teams to ensure alignment on regulatory and operational issues.
• Develop and maintain compliance oversight protocols, ensuring adherence to expedited timelines and regulatory expectations.
• Identify operational and compliance gaps and develop and implement mitigation plans.
• Collaborate with business leaders to ensure departmental policies and workflows are compliant and reflect current regulatory requirements.
• Partner with Quality and Audit teams to prepare for and respond to CMS and an active participate in all internal, NCQA, internal and departmental mock audits.
• Compliance reporting tools to track performance, identify trends, and escalate risks to ELT and key business partners such as Medicare Operations Integrity and Medicare Compliance.
• Create and manage a long-term operational strategy to manage appeals, and audit responses.
• Establish and lead cross-functional workgroups to address compliance risks, implement new regulatory requirements, drive continuous improvement, and participate.
• Monitor ongoing compliance across business units, conduct risk assessments, and assist with audits.
• Drive the planning and execution of projects related to compliance and regulatory requirements.

Required Qualifications

• 7+ years Medicare experience related to the duties and responsibilities specified or an equivalent combination of education and work experience.
• 7+ years of CMS audit, Medicare compliance or service operations experience.
• Ability to understand complex problems and collaborate with business leaders to plan, solve, and execute solutions.
• Experience working directly with CMS or other regulatory entities.

Preferred Qualifications

Clinical licensure (RN)

Education

Associate's degree or equivalent work experience

Pay Range

The typical pay range for this role is:

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.

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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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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