Senior Manager, Medicaid Compliance - Provider Data Services; PDS

Position: Senior Manager, Medicaid Compliance - Provider Data Services (PDS)
Location: Tennessee

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.

Position Summary The Senior Manager, Medicaid Compliance - Provider Data Services (PDS) is a senior-level role responsible for advancing provider data compliance, audit readiness, and risk mitigation across markets. This role serves as a subject matter expert, leading audit readiness and execution, including centralized tracking, audit coordination, and executive reporting.

The position drives the development and implementation of standardized, scalable audit and compliance frameworks, including audit playbooks and corrective action (CAP) oversight. It ensures remediation efforts are aligned to root cause, effectively implemented, sustainable, and supported by audit-defensible documentation. Through proactive monitoring, analytics, and issue resolution, the role strengthens controls, identifies risks, and enhances overall compliance performance.

Operating with a high degree of autonomy, this individual partners across Compliance, Legal, Credentialing, Network, Operations, and Technology to influence outcomes and promote consistent, compliant practices. The ideal candidate is a strategic, results-oriented leader with strong compliance expertise, analytical capabilities, and the ability to influence without authority, delivering measurable improvements in audit performance, data integrity, and regulatory compliance.

Key Responsibilities:

Audit Readiness & Execution:
Lead end-to-end audit readiness and execution for internal and external audits, including coordination, evidence validation, and submission of accurate, complete, and audit-defensible responses; proactively identify and escalate risks, issues, and dependencies to prevent delays.

Audit Tracking & Executive Reporting:
Establish and maintain centralized tracking of audit activity (RFIs, deliverables, findings, and CAPs), monitor progress against timelines, validate status accuracy, and deliver clear, executive-ready reporting on audit performance, key risks, and outcomes.

CAP & Remediation Oversight:
Drive development, tracking, and validation of corrective action plans aligned to root cause; ensure milestones, ownership, and dependencies are clearly defined; proactively escalate at-risk items; and confirm remediation is effectively implemented and supported by audit-ready documentation.

Compliance Oversight & SME Leadership:
Serve as a subject matter expert on Medicaid regulatory requirements and high-risk provider data processes (e.g., terminations, sanctions, directory accuracy, system integrations), ensuring operational practices align with compliance and contractual expectations.

Analytics, Monitoring & Continuous Improvement:
Leverage data analysis, reporting, and automation to identify trends and emerging risks, perform root cause analysis of complex issues, and drive continuous improvements that strengthen controls and enhance compliance performance.

Cross-Functional Influence & Capability Building:
Build strong partnerships across Compliance, Credentialing, Network, Operations, and Technology; influence stakeholders to drive accountability and compliant outcomes; and provide coaching and guidance to promote audit readiness and a culture of continuous improvement.

Required Qualifications 7+ years of experience in provider data, healthcare compliance, or related operations.
3+ years proven success leading audits and compliance initiatives with measurable outcomes.

Strong knowledge of healthcare regulatory requirements, risks, and internal control frameworks.

Exceptional communication skills with the ability to convey complex information clearly and concisely.

Demonstrated ability to operate effectively in a fast-paced, evolving environment while maintaining quality and compliance standards.

Preferred…