Sr Manager Corporate Compliance-Special Needs Plans (Clinical)

Job Summary

The Senior Manager, Corporate Compliance helps ensure the company's Medicare and Medicaid health plan programs follow all federal and state regulations. This role leads compliance efforts for Special Needs Plans (SNPs), identifies and reduces compliance risks, supports audits and regulatory reviews, and works closely with business leaders and government agencies. The position requires strong knowledge of Medicare, Medicaid, and healthcare regulations, along with excellent communication and project management skills.

Key Responsibilities

• Serve as the compliance lead for assigned Special Needs Plans (SNPs).
• Monitor and interpret CMS, state, and contract requirements and communicate compliance expectations to business teams.
• Develop, implement, and oversee compliance programs, including:
  • Risk assessments
  • Auditing and monitoring activities
  • Corrective action plans
• Ensure company operations comply with Medicare, Medicaid, and state regulations, as well as the CVS Code of Conduct.
• Provide compliance guidance and recommendations to leadership and business partners.
• Support communications and interactions with regulators, including responding to regulatory inquiries.
• Lead or support CMS and state regulatory audits from preparation through corrective action completion.
• Build strong relationships with internal leaders and external regulatory agencies.
• Conduct compliance reviews, identify issues, recommend solutions, and track corrective actions.
• Use compliance management tools and Microsoft Office applications to manage compliance activities.
• Support broader corporate compliance initiatives and special projects as needed.

Qualifications for Success

• Deep knowledge of Medicare and Medicaid compliance requirements, especially for Special Needs Plans (SNPs).
• Strong experience with auditing, monitoring, root cause analysis, and corrective action management.
• Excellent project management, organizational, and time-management skills.
• Ability to analyze complex regulations and explain requirements clearly to business teams.
• Strong problem-solving, decision-making, collaboration, and communication skills.
• Comfortable working in a highly matrixed organization and managing multiple priorities.

Required Qualifications

• Minimum 7 years of experience in Medicare, Medicare Advantage, healthcare compliance, or regulatory affairs.
• 2+ years of project management experience.
• Ability to travel up to 10% if necessary.

Preferred Qualifications

• Clinical or healthcare operations background (RN, LPN, Social Worker, or similar).
• Experience with SNP Model of Care (MOC) requirements and external quality reviews.
• Experience reviewing health risk assessments, care plans, claims, clinical documentation, and quality programs.

Ideal Candidate

An experienced healthcare compliance professional with strong Medicare and Medicaid expertise who can lead compliance programs, manage regulatory audits, influence senior stakeholders, and ensure Special Needs Plans operate in full compliance with regulatory requirements.