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Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary
Serves as the single point of contact for State Medicaid, Medicare programs for all program integrity related issues. This includes regulatory reporting, coordinating interdepartmental program integrity initiatives, vendor oversight of fraud waste and abuse (FWA) activity, and identifying services at risk for FWA. You will be responsible for compliance with state and federal regulations mandating the reporting of corporate fraud related activities and the preparation of the corporate Anti-Fraud Plan.

Additionally, you will:

• Utilize your experience and knowledge to comprehend and implement Medicaid regulations and contracts
• Coordinate with department leaders to fulfill the requirements of the program integrity unit
• Comply with all program integrity related requests, both internal and external, and meet request timelines
• Ability to handle and maintain confidential and sensitive information pertaining to providers.
• Maintain the Annual Fraud Plan, Risk Assessments and Work Plan including any health plan addendums
• Collaboration with plan compliance teams, including Audit preparation and Readiness Review oversight
• Act as a liaison with state Medicaid agencies, MFCU and other state law enforcement
• State reporting oversight and submission, as well as coordination of Vendor FWA activities
• Draft requests for proposal on new/rebidding of contracts
• Annual plan FWA training
• To be successful, you will utilize your excellent stakeholder relationship management skills to collaborate with state partners and internal
  teams. Your ability to organize and manage multiplies priorities will also be critical to your success.
• Regional Program Integrity role

Required Qualifications

• 7 years of work experience required (graduate level education may substitute)
• Experience in a Healthcare Program Integrity, Medicaid Special Investigation or Medicaid / Medicare / Commercial Compliance role
• Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)
• Must be located in the United States

Preferred Qualifications

• Experience In Medicaid Compliance, Medicaid Investigations, MCO Medicaid FWA Unit in the following States: Florida, Illinois, Michigan, Maryland, Pennsylvania
• Experience with Generating / Review Medicaid State Reporting
• Experience with Interpreting Contracts
• Exceptional Organizational Skills
• Excellent Written and Oral Communication Skills
• Ability To Interact with All Levels of The Organization.
• Working experience with Regulatory Agencies as SME or Lead Point of Contact

Education

• Bachelor’s degree or equivalent experience

Pay Range

The typical pay range for this role is:

$66,330.00 - $145,860.00

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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 04/21/2025

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