Description

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 Lead Director - Medicare Rework Reduction and Claims Operations is responsible for enterprise-level leadership, execution, and oversight of Medicare claims operations with a primary focus on reducing rework, improving first-pass accuracy, and strengthening operational performance.

This role provides end-to-end (E2E) accountability across Medicare claims processing, including intake, adjudication, payment, and post-payment activities, while directly leading both exempt leaders and non-exempt operational teams. The position ensures day-to-day claims operations are executed efficiently, compliantly, and in alignment with enterprise service, quality, and financial objectives.

Building on established Service Operations leadership, this role integrates hands-on operational management, people leadership, and strategic rework reduction initiatives to drive measurable improvements in service delivery, cost, compliance, and customer/provider experience. The Lead Director defines priorities, ensures disciplined execution, manages frontline and leadership performance, and delivers executive-level insights on progress, risks, and outcomes.

Through strong operational oversight and leadership of both strategy and execution, this role drives sustained reductions in rework, strengthens claims processing integrity, and enhances overall Medicare operational effectiveness.

Key Responsibilities

Strategic Leadership & Rework Reduction Ownership

• Develops and leads enterprise-wide Medicare rework reduction strategy aligned to service, quality, and compliance objectives.

• Owns E2E rework reduction workstreams across all phases of Medicare claims processing.

• Establishes clear accountability, milestones, and success metrics; ensures sustained execution and results.

• Monitors outcomes and drives timely corrective actions when performance deviates from targets.

Medicare Claims Operations Leadership

• Provides direct oversight of Medicare claims operations, including daily production, workflow management, and service delivery performance.

• Ensures claims are processed accurately, timely, and in compliance with regulatory and internal requirements.

• Oversees capacity planning, volume management, and workload distribution across teams.

• Drives consistency and standardization across claim processing activities to prevent defects and rework.

• Partners with supporting functions (e.g., enrollment, configuration, provider data) to resolve upstream drivers of claim issues.

Operational Excellence & Service Optimization

• Develops and executes strategies to optimize service delivery and claims processing efficiency.

• Implements best practices and process improvements to reduce defects, streamline workflows, and enhance productivity.

• Drives improvements in first-pass accuracy and reduces downstream rework and escalation volume.

• Ensures strong operational governance to prevent rework migration across teams or functions.

Performance Management, KPIs & Reporting

• Establishes and monitors KPIs for rework, quality, timeliness, productivity, and customer satisfaction.

• Holds leaders and frontline teams accountable for performance outcomes and service standards.

• Provides executive-level reporting on progress, risks, root causes, and corrective actions.

• Leverages data and trend analysis to identify systemic issues and prioritize improvements.

Technology, Data & Analytics Enablement

• Partners with IT and data teams to deploy tools, automation, and analytics that improve claims accuracy and efficiency.

• Evaluates and implements technology solutions that support rework prevention and operational effectiveness.

• Promotes adoption of systems and tools to ensure consistency and sustainability of process improvements.

Customer Experience & Quality Focus

• Drives a customer-centric culture focused on service excellence for members and providers.

• Monitors feedback, complaints, and escalations to identify improvement opportunities.

• Ensures complex or escalated issues are resolved with root-cause correction to prevent repeat defects.

• Aligns quality improvement efforts with rework reduction and service goals.

People Leadership & Team Management

• Provides direct leadership and management of both exempt leaders and non-exempt staff within Medicare claims operations.

• Sets clear performance expectations and ensures accountability for productivity, quality, and service outcomes.

• Oversees hiring, coaching, performance management, and development of frontline and leadership teams.

• Builds a high-performance, engagement-focused culture emphasizing ownership, execution, and continuous improvement.

• Ensures appropriate staffing levels, training, and onboarding to meet operational demands.

Resource, Risk & Compliance Stewardship

• Manages resources to support operational needs and rework reduction priorities while maintaining cost efficiency.

• Strengthens operational controls to mitigate compliance, financial, and regulatory risk.

• Partners with Compliance, Audit, and Risk teams to ensure corrective actions are effective and sustainable.

• Ensures alignment with CMS regulations and organizational risk tolerance.

Cross-Functional Collaboration

• Collaborates with Service Operations, IT, Quality, Compliance, Product, and Data teams to implement integrated solutions.

• Serves as a key point of accountability for cross-functional initiatives impacting Medicare claims performance.

• Communicates clearly with senior leadership to align priorities, risks, and decisions.

• operational leadership, including direct management of frontline teams.

• Demonstrated experience managing both exempt leadership and non-exempt staff in a high-volume production environment.

• Proven ability to lead end-to-end claims operations and large-scale performance improvement initiatives, including rework reduction.

• Strong expertise in operational performance management, workforce management, and KPI execution.

• Advanced proficiency in data analysis, business intelligence, and performance reporting.

• Experience working in highly regulated environments with strong knowledge of compliance and audit expectations.

• Proven ability to influence across a matrixed organization and drive cross-functional alignment.

• Strong problem-solving, decision-making, and execution skills with a focus on measurable outcomes.

Required Qualifications

10-15 years of progressive experience in Medicare claims operations, service operations, or operational leadership, including direct management of frontline teams.

• Demonstrated experience managing both exempt leadership and non-exempt staff in a high-volume production environment.

• Proven ability to lead end-to-end claims operations and large-scale performance improvement initiatives, including rework reduction.

• Strong expertise in operational performance management, workforce management, and KPI execution.

• Advanced proficiency in data analysis, business intelligence, and performance reporting.

• Experience working in highly regulated environments with strong knowledge of compliance and audit expectations.

• Proven ability to influence across a matrixed organization and drive cross-functional alignment.

• Strong problem-solving, decision-making, and execution skills with a focus on measurable outcomes.

Education
High School Diploma - based on experience; Bachelor's preferred or equiv. work experience

Pay Range

The typical pay range for this role is:

$100,000.00 - $231,540.00

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: 06/10/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.