Manager, Medicare Compliance Job at CVS Health (Work at Home)

Director Utilization Management

The Director of Utilization Management is a strategic clinical operations leader...

Location

United States , New York

Salary:

154600.00 - 236555.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Bachelor’s degree in healthcare, business, or a related field from an accredited institution or equivalent work experience
Progressive leadership experience in healthcare management including work experience in a mid-senior management role
Work experience and deep familiarity of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP)
Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
Work experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS
Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions
Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment

Job Responsibility

Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests
Develop strong operational and leadership capabilities within the organization through performance improvement, career development, and coaching
Develop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirements
Deliver on Healthfirst’s Mission by ensuring optimum quality of member care in a cost-effective manner
Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
Develop and monitor appropriate metrics to maintain and improve department performance
Collect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvement
Lead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technology
Serve as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiatives
Collaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions

What we offer

medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions

Fulltime

New

Senior Manager, Corporate Compliance (Medicare Duals)

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Downers Grove

Salary:

82940.00 - 182549.00 USD / Year

CVS Health

Expiration Date

February 28, 2026

Requirements

7+ years’ experience in Medicare or Medicare Advantage government healthcare program compliance or regulatory work
2+ years of Project Management experience
Ability to travel up to 10%
Bachelor’s Degree required
Extensive knowledge of Medicare and Medicaid compliance programs and rules, including rules applying to integrated duals plans
Experience in validation, auditing and monitoring, root cause analysis and corrective action oversight
Outstanding time management and project management
Proficient in utilization of information systems
Mastery of problem solving and decision-making skills
Adept at execution and delivery (planning, delivering, and supporting) skills

Job Responsibility

Serve as plan compliance officer for assigned Special Needs Plans (SNPs)
Lead and implement an effective Compliance Program as described in CMS Medicare Managed Care Manuals/regulations, applicable Medicaid rules and government contracts, including risk assessment, auditing and monitoring and corrective action oversight
Develop and manage compliance strategies, programs, and processes that promote compliant and ethical behavior, meet regulatory obligations, and prevent, detect, and mitigate compliance risks
Track, analyze, research, interpret and monitor applicable CMS and state regulations and government contract requirements to develop recommendations, direction, and escalation ensuring Aetna’s that implementation and integration of program requirements complies with federal and state specific program requirements and the CVS Code of Conduct
Maintain in-depth working knowledge and expertise in Medicare, Medicaid and State requirements, regulations and contracts with a focus on supporting special needs plans
Facilitate compliance and contract related communications, deliverables and activities with regulators
Manage to ensure timely and accurate responses and tracking of multiple complex regulatory interactions, including frequent meeting with regulators on compliance with laws and regulations, developing or assisting in the development of appropriate and strategic written responses to compliance-related regulatory inquiries requiring an understanding of business processes and regulatory requirements and positive relationships with regulators
Leads and/or supports numerous external regulatory review and audit activities, including the preparation for and management of external audits conducted by state Medicaid and related agencies or partners in conjunction with health plan leadership through final report and corrective action plan closure
Builds and maintains positive relationships with internal and external constituents at senior levels to drive decision-making and influence ethical and compliant outcomes
Monitor and audit as outlined in Medicare Compliance Work Plan and direct other projects as assigned to evaluate compliance, propose remediation where necessary and monitor implementation of corrective action

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance

Fulltime

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Regulatory Compliance Manager

We are seeking a Regulatory Compliance Manager to join our Insurance Compliance ...

Location

United States

Salary:

130000.00 USD / Year

Axiom Law

Expiration Date

Until further notice

Requirements

Bachelor’s degree required
Juris Doctor (JD) or equivalent strongly preferred
7+ years of commercial insurance experience
7+ years of compliance-related experience, including MSP compliance
Demonstrated experience managing Medicare Secondary Payer compliance programs
Ability to lead teams with varied backgrounds across multiple locations
Strong analytical skills with the ability to exercise sound professional judgment

Job Responsibility

Lead and oversee a sustainable, enterprise-wide Medicare Secondary Payer (MSP) compliance program, including: Evaluating and maintaining Medicare Responsible Reporting Entity (RRE) IDs
Managing claims data collection and reporting across multiple claims systems
Monitoring reporting accuracy, error rates, and corrective actions
Implement and maintain processes for: Creation and ongoing management of RRE IDs
Training, guidance, and oversight to ensure personnel awareness of MSP data collection and reporting requirements
Ensure segment teams, operating units, and corporate leadership receive timely and accurate information regarding: Medicare reporting activities
Compliance deficiencies
Corrective action plans
Monitor legal and regulatory developments related to MSP compliance and update the compliance program accordingly
Conduct regular meetings with segment teams, operating unit personnel, and corporate leadership to: Maintain effective working relationships

What we offer

Health benefits
401K
Professional development resources
Learning and development programs

Fulltime

Utilization Management Physician Reviewer

Full-time role responsible for provisioning accurate and timely coverage determi...

Location

United States , Remote

Salary:

174070.00 - 374920.00 USD / Year

CVS Health

Expiration Date

August 21, 2026

Requirements

At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business
Excellent verbal and written communication skills
A current, clinical, unrestricted license to practice medicine in the United States
Graduate of an accredited medical school with M.D. or D.O. Degree
3-5 years of clinical practice in a primary care setting
Deep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management
Strong record of continuing education activities
Demonstrated understanding of culturally responsive care
Proven organizational and detail-orientation skills
US work authorization

Job Responsibility

Review service requests and document the rationale for the decision
Use evidence-based criteria and clinical reasoning to make UM determinations
Work collaboratively with the Oak Street Health Transitional Care and PCP care teams
Maintain knowledge of current CMS and MCG evidence-based guidelines
Maintain compliance with legal, regulatory and accreditation requirements
Participate in initiatives to achieve and improve UM imperatives
Assist in formal responses to health plan regarding UM process
Adhere to regulatory and accreditation requirements of payor partners
Participate in rounding and patient panel management discussions
Fulfill on-call requirement

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources

Fulltime

Network Relations Manager

At CVS Health, we are focused on transforming health care by building a world of...

Location

United States , Massachusetts; Rhode Island

Salary:

66330.00 - 145860.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

4+ years' experience in business segment specific environment servicing or managing non-standard relationships with providers with exposure to benefit plan design and/or contract interpretation
3-5 years' experience with business segment specific policy, benefits, plan design and language
Working knowledge of business segment specific codes, products, and terminology
1-2 years of Medicare and Commercial background

Job Responsibility

Acts as the primary resource for assigned profile of larger and more complex providers to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs
Drives the implementation of internal and external solutions to achieve provider satisfaction, cost targets, network growth, and efficiency targets
Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships
Monitors service capabilities and collaborates cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information are resolved
Supports or assists with operational activities that may include, but are not limited to, database management, and contract coordination
Performs credentialing support activities as needed
Educates providers as needed to ensure compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures
Meets with key providers periodically to ensure service levels are meeting expectations
Manages the development of agenda, validates materials, and facilitates external provider meetings
Conduct standard provider recruitment, contracting, or recontracting activities and assist with more complex contracting and discussions as needed by business segment

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost wellness programs including wellness screenings, tobacco cessation, and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Tuition assistance

Fulltime

Medicare Compliance Officer

Develops, operates and administers the regulatory compliance program for both Me...

Location

United States , Phoenix

Salary:

43.10 - 64.11 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Bachelors Other or an equivalent combination of directly related work experience and/or education
Five (5) years of experience that demonstrates solid Medicare compliance program development, operation and administration responsibilities

Job Responsibility

Develops, operates and administers the regulatory compliance program for both Medicare Advantage (Part C) and Medicare Part-D plan activities for Mercy Care Plan
Reports directly to the Plan CEO and the Audit and Compliance Committee of the Board of Directors
Develops and monitors the implementation of and compliance with Medicare policies and procedures through the creation and implementation of a work plan
Reports, at least on a quarterly basis, or more frequently as necessary, to the board of directors, president and/or CEO, and compliance committee, on the status of Mercy Care Plan's Medicare compliance program implementation, the identification and resolution of potential or actual instances of noncompliance, and the Plan's oversight and audit activities
Creates and coordinates, or appropriately delegates, educational training programs to ensure that the Plan's officers, directors, managers, employees, and other individuals working on the Medicare program are knowledgeable of Mercy Care Plan's compliance program
its written standards of conduct, policies, and procedures
and the applicable statutory, regulatory, and other requirements
Ensures that first tier entities, downstream entities, and related entities, particularly those involved in sales and marketing activities, are aware of and follow the requirements for Medicare sales and marketing activities
Briefs the compliance committee and governing body on the status of compliance training

What we offer

medical
prescription drug
dental
vision plans
life insurance
paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually)
tuition reimbursement
retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings

Fulltime

Embedded Transitional Care Manager RN

Oak Street Health takes a team-based approach to providing outstanding patient c...

Location

United States , Rockford

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

An active RN license within the state of practice in good standing
Willingness to obtain cross-state licensure, as needed
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
Experience in utilization management preferred
Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
Exceptional communication skills and customer service orientation
Innovative and independent problem solving skills
Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required

Job Responsibility

Manage patients through transitions of care
Advocate for the patient throughout the care continuum
Identify opportunities for improved program workflows
Maintain real-time and accurate records of patient status
Adhere to CMS, state specific and NCQA compliance criteria
Evaluate patient status post-ED visit or observation stay
Triage to determine appropriate follow up care
Engage directly with inpatient physicians, case managers, medical directors, and hospitalists
Coordinate with the Utilization Management team
Conduct structured clinical assessment to identify post-discharge needs

What we offer

Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Affordable medical plan options
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

Fulltime

Audit Manager

Reed is seeking an Audit Manager who is experienced in federal or state financia...

Location

United States , Essex

Salary:

Not provided

Reed & Associates, CPAs

Expiration Date

Until further notice

Requirements

Current CPA status
U.S. Citizenship
Minimum 6 years of relevant work experience
Minimum 3 years of supervisory experience
Plan, organize, and manage audits
Demonstrated high level of expertise with Medicare, Federal Acquisition regulations and/or OMB Circulars
Solid understanding of informational systems
Ability to manage all aspects of client engagements
Well organized with a high degree of accuracy and attention to detail
Strong analytical and problem solving skills

Job Responsibility

Develop and lead our audit team
Manage multiple engagements under awarded contracts or task orders
Run the full gamut, from building a team, audit staff onboarding, training, directional assignments and developmental leadership
Conduct audits including SSAE16, government sponsored health care programs (i.e. Medicare/Medicaid agencies), cost incurred, internal controls, compliance and performance in accordance with Government Auditing Standards
Manage multiple concurrent teams and audits
Budget control
Scope control
Staff performance evaluations
CPE tracking
Travel to audit locations throughout the United States

What we offer

Professional growth and development opportunities
Educational opportunities leading to certifications
A diverse, dynamic, and challenging work environment
Strong leadership, communication, and feedback
Creative and innovative solutions to challenges facing our government clients
Immediate hands-on experience
Opportunity for professional growth
Competitive compensation commensurate with experience
Bonuses for business development
A complete benefits package

Fulltime

Manager, Medicare Compliance

CVS Health

Location:
United States , Work at Home

Category:
-

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 25, 2026

Expiration:
February 27, 2026

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Job Description:

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Location:
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Category:
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Contract Type:
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Job Posted:
February 25, 2026

Expiration:
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