Business Compliance Manager, CVS Health

CVS Health

Location:
United States, Remote

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

Not provided

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Job Description:

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. You will lead a team responsible for ensuring the quality and integrity of healthcare fraud and abuse investigations.

Job Responsibility:

Lead a team of Quality Reviewers to effectively assess the prevention, investigation, and prosecution of healthcare fraud and abuse, ensuring the recovery of lost funds
Oversee the planning and execution of quality reviews for investigations related to acts of healthcare fraud and abuse by both members and providers
Provide direction and counsel on case handling, facilitating issue resolution and ensuring high-quality investigations
Assist in identifying resources and determining the best course of action in a timely and effective manner
Conduct comprehensive case reviews and provide constructive feedback to team members on the completeness and quality of their investigations
Evaluate team members and provide ongoing performance feedback to support their professional development
Manage the workload of the team to ensure equitable distribution and exposure to a wide range of cases, aligning with current skills and development needs
Assess training needs and collaborate with the SIU Sr. Manager to create development plans for team members
Develop and maintain strong working relationships with federal, state, and local law enforcement agencies to support the investigation and prosecution of healthcare fraud and abuse
Participate in state meetings and ensure compliance with contractual requirements
Coordinate and collaborate with compliance and senior leadership to align on program integrity initiatives
Contribute to the development and delivery of educational awareness and training programs that meet or exceed state mandates
Participate in federal and state audits to ensure adherence to regulations and standards
This role ensures that all aspects of the RFP lifecycle are effectively coordinated to meet organizational goals and deadlines
Oversee vendor managing, working closely with both internal and external clients
Managing multiple projects while leading a production team

Requirements:

Minimum of five years of experience managing healthcare fraud, waste, and abuse investigations, Compliance Auditing, Program Integrity, Regulatory Oversight, Production Monitoring
At least four years of people leading experience is required
Documented record of leading a team greater than eight colleagues
Experience collaborating with state and law enforcement partners
Experience in project management, with the ability to manage multiple priorities and projects simultaneously while meeting deadlines
Strong verbal and written communication skills
Ability to interact effectively with diverse groups of people at various levels and provide timely assistance
Proficient in researching information and identifying relevant resources
Candidates must possess comprehensive knowledge and proficiency in Microsoft Word, Excel, Outlook, SharePoint, QuickBase Management and Visio as well as experience with data analysis tools
Strong analytical skills and the ability to effectively utilize these applications to support data-driven decision-making are essential
Ability to travel up to 20% (approximately 6-9 times per year, depending on business needs)
Present in large group sessions via videoconference or in person setting as defined by leadership

Nice to have:

Relevant certifications such as Certified Compliance and Ethics Professional (CCEP), Certified Fraud Examiner (CFE), or similar credentials
Proven experience in managing a quality assurance team, including training and development of staff
Knowledge of company policies and procedures
Familiarity with Medicaid and Medicare plans

What we offer:

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access
Health-focused benefits including wellness programs and services

Additional Information:

Job Posted:
April 29, 2025

Expiration:
May 30, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Business Compliance Manager