Business Compliance Manager (Aetna SIU) at CVS Health Phoenix, AZ

Position Summary

As the Manager of Business Compliance of Quality Review, Training, and Program Integrity, you will lead a team responsible for ensuring the quality and integrity of healthcare fraud and abuse investigations. This role involves overseeing the training and development of team members, managing quality review processes, and ensuring compliance with state regulations and contractual requirements.

Flexible on location and remote opportunities are available across many locations.

• Lead a team of Quality Reviewers to effectively assess the prevention, investigation, and prosecution of healthcare fraud and abuse, ensuring the recovery of lost funds.
• Oversee the planning and execution of quality reviews for investigations related to acts of healthcare fraud and abuse by both members and providers.
• Provide direction and counsel on case handling, facilitating issue resolution and ensuring high-quality investigations.
• Assist in identifying resources and determining the best course of action in a timely and effective manner.
• Conduct comprehensive case reviews and provide constructive feedback to team members on the completeness and quality of their investigations.
• Evaluate team members and provide ongoing performance feedback to support their professional development.
• Manage the workload of the team to ensure equitable distribution and exposure to a wide range of cases, aligning with current skills and development needs.
• Assess training needs and collaborate with the SIU Sr. Manager to create development plans for team members.
• Develop and maintain strong working relationships with federal, state, and local law enforcement agencies to support the investigation and prosecution of healthcare fraud and abuse.
• Participate in state meetings and ensure compliance with contractual requirements.
• Coordinate and collaborate with compliance and senior leadership to align on program integrity initiatives.
• Contribute to the development and delivery of educational awareness and training programs that meet or exceed state mandates.
• Participate in federal and state audits to ensure adherence to regulations and standards.
• This role ensures that all aspects of the RFP lifecycle are effectively coordinated to meet organizational goals and deadlines.
• Oversee vendor managing, working closely with both internal and external clients.
• Managing multiple projects while leading a production team.
• Flexible on location.

• Minimum of five years of experience managing healthcare fraud, waste, and abuse investigations, compliance auditing, program integrity, regulatory oversight, and production monitoring.
• At least four years of people‑leading experience is required.
• Documented record of leading a team greater than eight colleagues.
• Experience collaborating with state and law enforcement partners.
• Experience in project management, with the ability to manage multiple priorities and projects simultaneously while meeting deadlines.
• Strong verbal and written communication skills.
• Ability to interact effectively with diverse groups of people at various levels and provide timely assistance.
• Proficient in researching information and identifying relevant resources.
• Comprehensive knowledge and proficiency in Microsoft Word, Excel, Outlook, SharePoint, Quick Base Management, and Visio, as well as experience with data analysis tools.
• Strong analytical skills and the ability to effectively utilize these applications to support data‑driven decision‑making are essential.
• Ability to travel up to 20% (approximately 6–9 times per year, depending on business needs).
• Present in large group sessions via video conference or in person as defined by leadership.

• Relevant certifications such as Certified Compliance and Ethics Professional (CCEP), Certified Fraud Examiner (CFE), or similar credentials.
• Proven experience in managing a quality assurance team, including training and development of staff.
• Knowledge of company policies and procedures.
• Familiarity with Medicaid and Medicare plans.

Bachelor's degree in Business Administration, Healthcare Administration, Criminal Justice, or a related field or…