Executive Director, Medicaid Program Integrity

Key Responsibilities Develop and execute enterprise-wide Program Integrity and Regulatory Affairs strategies that support Medicaid business objectives, regulatory compliance requirements, operational effectiveness, and long-term growth initiatives.

Provide executive oversight of Medicaid Payment Integrity programs, including payment accuracy, overpayment recovery, fraud, waste and abuse prevention, provider oversight, auditing, monitoring, investigations, and compliance activities.

Lead and develop a high-performing team responsible for managing all government agency requirements related to Medicaid Program Integrity and Payment Integrity programs.

Serve as the executive liaison with state Medicaid agencies, Medicaid Fraud Control Units (MFCUs), CMS, auditors, regulators, and other governmental entities.

Direct organizational responses to regulatory audits, investigations, corrective action plans, Requests for Information (RFIs), and state and federal reporting obligations.

Monitor and interpret federal and state regulatory changes impacting Medicaid and Payment Integrity programs and develop strategies to ensure ongoing compliance, operational readiness, and business continuity.

Partner with Compliance, Legal, Special Investigations Unit (SIU), Claims, Network, Operations, Finance, Government Affairs, and Medicaid market leadership to ensure enterprise alignment on Program Integrity priorities.

Establish enterprise-wide policies, governance frameworks, controls, methodologies, and best practices that drive consistency, accountability, and compliance across Medicaid markets.

Lead the identification, evaluation, and implementation of strategic opportunities to enhance Payment Integrity capabilities, improve payment accuracy, reduce financial risk, and support organizational growth.

Oversee development and implementation of compliance monitoring programs, audits, and assessments designed to evaluate and improve Program Integrity effectiveness.

Develop executive-level business cases and recommendations supporting program expansion, operational improvements, regulatory readiness, and strategic investments.

Represent the organization in meetings, hearings, industry forums, and discussions with regulators, government officials, legislative bodies, and external stakeholders.

Communicate regulatory risks, opportunities, emerging trends, and business impacts to executive leadership and support enterprise decision-making.

Establish governance processes for documenting decisions, regulatory commitments, policy changes, and strategic growth initiatives across Medicaid markets.

Develop and champion training, education, and knowledge-sharing programs that strengthen organizational understanding of Program Integrity requirements and best practices.

Lead organizational transformation and process improvement initiatives that enhance effectiveness, scalability, compliance performance, and operational efficiency.

Manage team performance through coaching, talent development, succession planning, performance management, and retention strategies.

Qualifications The candidate will have a strong work ethic, be a self-starter, and be able to be highly productive in a dynamic, collaborative environment.

This position offers broad exposure to all aspects of the company's business, as well as significant interaction with all the business leaders.

The candidate will be expected to have the following key attributes: 12+ years of progressive leadership experience in Medicaid Program Integrity, Payment Integrity, Compliance, Managed Care Operations, Healthcare Operations, or a related healthcare function.

Deep expertise in Medicaid managed care regulations, state Medicaid contracts, CMS requirements, fraud, waste and abuse (FWA) programs, and Medicaid Program Integrity operations.

Demonstrated leadership of enterprise-wide Program Integrity, Payment Integrity, Regulatory Affairs, Compliance, or operational functions within a complex healthcare organization.

Proven experience serving as a primary executive liaison with state Medicaid agencies, CMS, Medicaid Fraud Control Units (MFCUs), auditors, regulators, and other governmental entities.

Significant experience leading regulatory audits, investigations, corrective action plans, Requests for Information (RFIs), regulatory examinations, and government reporting activities.

Demonstrated success developing and executing enterprise and multi-year strategic plans that align regulatory requirements, operational priorities, and business growth objectives.

Strong knowledge of Payment Integrity operations claims payment accuracy, overpayment recovery methodologies, fraud prevention programs, provider oversight, auditing, and compliance monitoring.

Proven ability to influence executive leadership and drive enterprise-wide decision-making within a highly matrixed organization. Demonstrated success leading large-scale transformational initiatives, organizational change efforts, and process improvement programs.

Experience building, leading, and developing high-performing teams responsible for regulatory, operational, compliance, or Program Integrity functions.

Exceptional executive communication, stakeholder management, negotiation, and relationship-building skills. Demonstrated ability to analyze complex regulatory, operational, and financial issues and translate findings into strategic business solutions.

Education Bachelor's degree or equivalent work experience. Pay Range The typical pay range for this role is: $131,500.00 - $303,195.00 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.

This position also includes an award target in the company's equity award program. 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.

The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 08/11/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Our Work Experience is the combination of everything that's unique

about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people.

Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.