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.
As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
As the Manger of Business Compliance of Quality Review, Training, and Program Integrity. You will lead a team responsible for ensuring the quality and integrity of healthcare fraud and abuse investigations. This role involves overseeing the training and development of team members, managing quality review processes, and ensuring compliance with state regulations and contractual requirements.
Position Summary
As the Manger of Business Compliance of Quality Review, Training, and Program Integrity. You will lead a team responsible for ensuring the quality and integrity of healthcare fraud and abuse investigations. This role involves overseeing the training and development of team members, managing quality review processes, and ensuring compliance with state regulations and contractual requirements.
What You Will Do
- 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.
- Flexible on location.
Required Qualifications
- 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.
Preferred Qualifications
- 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.
Education
- Bachelor’s degree in Business Administration, Healthcare Administration, Criminal Justice, or a related field or equivalent experience.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$54,300.00 - $159,120.00
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.
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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
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Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
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No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
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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 and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 05/30/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Top Skills
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners.
Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
