Senior Manager MPPS Policy Consultation

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

May reside anywhere in US

The Senior Manager MPPS Policy Consultation is responsible for the identification, development, and execution of clinical and payment policies, ensuring alignment with evidence-based guidelines, regulatory requirements, and enterprise affordability goals.

This role serves as a subject matter expert (SME) bridging clinical policy, coding, and claims adjudication by translating clinical and payment policy intent into clear business requirements that drive accurate configuration and enforcement within claims processing platforms.

The position partners across Medical Policy, Medical Coding, Compliance, and vendor teams to ensure policy is operationalized consistently across end-to-end claims workflows (intake, edits, adjudication, denials, and appeals).

• Lead identification of new and emerging clinical and policy opportunities, including:
• Medical correct coding vulnerabilities
• Payment integrity risks
• Interpret clinical evidence, regulatory guidance, and industry best practices to:
• Develop or revise clinical or payment medical policies
• Define coverage criteria, limitations, and exclusions
• Ensure policies are clinically sound, evidence-based, and aligned with CMS/state guidance

• Define and drive payment policy strategies to ensure accurate claim adjudication and cost containment
• Translate policy intent into:
• Claims editing logic
• Correct coding requirements (DX, CPT/HCPCS, modifiers, frequency rules)
• Adjudication outcomes (deny, pend, allow, PA requirement)
• Partner with payment integrity and vendor teams (e.g., editing engines) to implement scalable solutions

• Own development of detailed Business Requirements Documents (BRDs) to support policy implementation, including:
• Policy intent and business objectives
• Coding and clinical logic
• Claims system behavior across adjudication points
• Configuration and testing requirements
• Ensure requirements are:
• Clear, actionable, and testable
• Aligned with claims platform capabilities (e.g., ACAS, QNXT, HRP)
• Act as the primary liaison between clinical SMEs and technical/configuration teams

• Partner with claims operations to ensure policy is correctly implemented across:
• Front-end edits
• Pre-payment edits
• Post-adjudication processes
• Validate that behavioral health policies are correctly translated into system logic and medical coding rules
• Support testing, defect resolution, and go-live readiness

• Perform policy QA and validation to ensure:
• Alignment between clinical intent and system execution
• Compliance with federal/state regulations and payer requirements
• Support audits and remediation efforts by:
• Identifying gaps in policy, medical coding, or configuration
• Driving corrective actions

• Serve as Clinical and Payment policy SME across:
• Medical Policy governance forums
• Payment policy and vendor edit work groups
• Partner with:
• Clinical teams
• Medical coding SMEs
• Compliance and legal
• IT and vendor partners
• Lead end-to-end policy lifecycle from intake through execution and monitoring

• 7+ years of experience in medical policy, payment policy, or correct coding; clinical practice;
• Abil…