MPPS Policy Customization Lead Director
North Carolina, USA
Listed on 2026-08-07
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Management
Change Management, Regulatory Compliance Specialist, Business Analyst, Project & Program Management
Lead Director, MPPS Policy Consultation
Lead Director, MPPS Policy Consultation directs medical, clinical, and payment policy SAI (Scorable Action Item) processes, leading teams to execute projects from initiation through completion. Collaborates cross-functionally as an expert policy advisor with clinical, coding, operations, compliance, and technology teams to deliver value to the organization. Secures required resources and formal processes and tools to manage resources, budgets, risk, and changes.
Assesses roadblocks to ensure on-time completion according to specifications and within budgeted costs. Collaborates as expert policy advisor with stakeholders (ie: Medical Economics, product lines, Network) to develop strategic plans for projects and programs delivering high-impact outcomes to improve policy performance, claim accuracy, and regulatory compliance. Prepares and presents SAI progress reports to stakeholders and senior management. Administers areas for continuous improvement in SAI lifecycle and ensures compliance, high performance standards, and quality outcomes.
Development & Implementation
- Directs research, authoring, evaluation, and implementation of medical, clinical, and payment policies bringing new value to the organization
- Makes certain policies are driven by evidence-based practices and supported by federal and state regulations
- Aligns with PI COE and other internal and external stakeholders throughout implementation, establishing clear business requirements and coding architecture for accurate configuration and operational success
- Leverage data-driven insights to inform strategic decisions and improvements
- Provides operational review teams direction on how to interpret policies for accurate review
- Directs and mentors a high-performing team of MPPS policy clinical and coding subject-matter leaders, project managers, and/or project coordinators
- Directs a portfolio of complex, cross-functional projects supporting MPPS initiatives throughout project life cycles (intake, planning, execution, monitoring, closure)
- Ensures projects are delivered on time, within scope, and aligned to business and regulatory objectives
- Directs adoption of standardized project management methodologies (e.g., Agile, Waterfall, hybrid)
- Implements continuous improvement initiatives to enhance delivery efficiency and quality
- Develops and maintains tools, templates, and SOPs to support consistent execution
- Communicates with executive leadership as a medical coding and policy expert
- Facilitates governance forums, decision-making bodies, and cross-functional working sessions
- Communicates program status, risks, and key decisions clearly to senior leadership and stakeholders
- Administers quality oversight of SAI initiatives, ensuring policies are performing financially and operationally as expected
- Establishes and tracks key performance indicators (KPIs) for project and program success
- Leads team of policy experts who support and provide expert testimony during regulatory investigations, state fair hearings, and CMS audits
- Implements proactive issue resolution and escalation strategies
- Ensures audit readiness and compliance with internal controls and regulatory requirements
- Delivers executive-level reporting on SAI progress, outcomes, and operational impact
Can work from anywhere in the US
Required Qualifications- 10+ years of experience in project or program management
- 10+ years of experience within healthcare (health plan, payer, or related environment), with emphasis on medical policy, payment integrity, and improvement of cost of care
- Strong understanding of Medicare and Medicaid regulations
- Demonstrated expertise leading cross-functional initiatives impacting operations, policy, or compliance
- Adept at execution and delivery (planning, delivering, and supporting)
- Advanced project/program management expertise across large-scale, cross-functional initiatives
- Mastery of problem-solving, prioritizing, and decision-making skills in a fast-paced environment
- Mastery of growth mindset approach (agility with developing…
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