Senior Manager – MPPS Policy Consultation

CVS Health

. Identify, develop, and execute clinical and payment policies .

Posted 10/6/2026full-timeRemote • United StatesSenior💰 $67,900 - $182,549 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in developing and executing clinical and payment policies, ensuring alignment with regulatory requirements and evidence-based guidelines. Proficient in translating policy intent into business requirements for claims processing and managing the end-to-end policy lifecycle.

Highest-signal resume keywords

Medical Policy DevelopmentBusiness Requirements Document (BRD) CreationICD-10 KnowledgeClaims Adjudication Platforms ExperienceCertified Professional Coder (CPC)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Payment Policy DevelopmentCorrect Coding FrameworksClaims Editing LogicClinical Standards InterpretationPolicy Quality AssuranceBehavioral Health Policy ValidationClaims System ConfigurationAdjudication Rules TranslationDefect ResolutionPolicy Implementation

Soft Skills

CollaborationProblem-SolvingCommunication

Tools & Technologies

Claims Processing PlatformsVendor Editing Solutions

Certifications & Qualifications

Certified Professional Coder (CPC)Certified Coding Specialist (CCS)

Industry Keywords

HealthcareRegulatory RequirementsEvidence-Based GuidelinesMedical Necessity Criteria ManagementGovernance Forums

About the role

Key responsibilities & impact

Identify, develop, and execute clinical and payment policies
Ensure policies align with evidence-based guidelines, regulatory requirements, and enterprise affordability goals
Translate clinical and payment policy intent into business requirements for claims processing platforms
Partner with Medical Policy, Medical Coding, Compliance, claims operations, IT, and vendor teams
Define coverage criteria, limitations, exclusions, claims editing logic, coding requirements, and adjudication outcomes
Develop detailed BRDs covering policy intent, coding and clinical logic, claims system behavior, configuration, and testing requirements
Ensure policy implementation across front-end, pre-payment, and post-adjudication processes
Validate behavioral health policies in system logic and medical coding rules
Support testing, defect resolution, and go-live readiness
Perform policy quality assurance and validation
Support audits and remediation by identifying gaps and driving corrective actions
Serve as a clinical and payment policy subject matter expert in governance forums and vendor edit workgroups
Lead the end-to-end policy lifecycle from intake through execution and monitoring

Requirements

What you’ll need

7+ years of experience in medical policy, payment policy, correct coding, or clinical practice
Ability to interpret clinical standards and translate them into policy
Knowledge of ICD-10, CPT/HCPCS, and correct coding frameworks
Experience developing Business Requirements Documents (BRDs) for claims system configuration
Strong knowledge of clinical and payment policies and medical necessity criteria management
Experience translating policy into medical coding logic, claims editing, and adjudication rules
Experience with claims adjudication platforms and/or vendor editing solutions
Bachelor’s degree in healthcare or a related field, or work-related experience
Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required, or obtained within one year of start date
Ability to work in the United States

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program
Award target in the company’s equity award program
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being