Lead Director - UM Center of Excellence

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Position Summary The Lead Director, UM Center of Excellence (UM COE), Policy & Process Governance is a strategic and operational leader responsible for enterprise governance of the content and resources that guide Utilization Management work. This role ensures UM policies, procedures, desktops, job aids, documentation templates, letters, fax forms, and related content are accurate, current, compliant, accessible, and aligned across lines of business. The Lead Director establishes governance standards, leads intake and prioritization, oversees content development and maintenance, chairs cross-functional decision forums, and partners with UM Operations and enterprise stakeholders to translate regulatory, accreditation, contractual, clinical, and operational requirements into clear, sustainable guidance for frontline teams.

• Set the strategy, operating model, standards, and priorities for UM policy and process governance across Commercial, Medicare, Medicaid, Duals, and other supported lines of business.
• Lead the development, review, approval, publication, maintenance, and annual review of UM policies, procedures, Medicaid policy amendments, desktops, job aids, documentation templates, UM letters, and fax forms.
• Ensure policies and procedures clearly define UM responsibilities, translate policy into structured workflows, and are formatted to support regulatory submission, licensure, accreditation, audit, and contractual requirements.
• Chair and mature governance forums for business content and job aids, establishing clear roles, decision rights, approval pathways, escalation practices, and accountability across participating functions.
• Own governance for the CS Hub and related content repositories, including release discipline, content quality, searchability, standard formatting, version control, and lifecycle management.
• Oversee intake and impact assessment for requests affecting UM documents and workflows, including operational changes, policy updates, regulatory or accreditation requirements, audit findings, corrections, questions, and system-related changes.
• Direct evaluation of current-state and future-state requirements, determine affected content and downstream impacts, and ensure updates receive appropriate stakeholder review and sign-off before publication.
• Partner with UM Operations, Medical Affairs, Legal, Compliance, NCQA, Quality and Audit, Training, Communications, Technology/DDAT, and other enterprise teams to maintain consistent, compliant, and usable guidance.
• Provide consultation on system enhancements and operational changes that affect UM workflows, documentation requirements, decision support, templates, letters, or content repositories.
• Establish and monitor performance measures for governance effectiveness, including intake volume, turnaround time, backlog, defects, compliance incidents, annual-review completion, adoption, usability, and release activity.
• Use data and stakeholder feedback to identify content gaps, simplify and standardize guidance, improve readability and usability, reduce defects, and strengthen the connection between policy and frontline execution.
• Ensure approved changes are communicated to impacted stakeholders and coordinated with operational readiness, training, communications, and audit partners as appropriate.
• Lead post-publication monitoring and continuous improvement to confirm content remains accurate, adopted, and responsive to evolving business, regulatory, and operational needs.
• Lead, coach, and develop a multidisciplinary team responsible for policy management, business content management, job aid and workflow governance, documentation templates, letters, forms, and intake support.
• Foster a culture of accountability, collaboration, disciplined governance, customer focus, and continuous improvement within the Policy & Process Governance team.

Required Qualifications

• 10-15 years of progressive experience in healthcare operations, Utilization Management, clinical operations, policy administration, process governance, compliance, or a related function, preferably within a health plan or managed care organization.
• Demonstrated leadership of enterprise policy, procedure, workflow, job aid, or business content governance in a complex, regulated environment.
• Deep understanding of Utilization Management operations and the relationship among policies, procedures, workflows, documentation, letters, systems, and frontline execution.· Working knowledge of healthcare regulatory and accreditation expectations, including CMS, NCQA, federal and state requirements, and Medicaid contractual considerations.
• Experience establishing governance models, facilitating cross-functional decision-making, managing intake and prioritization, and driving accountability for content quality and lifecycle management.
• Strong analytical capabilities with experience using operational metrics, dashboards, audit findings, and stakeholder feedback to improve performance and mitigate risk.
• Exceptional executive communication, stakeholder engagement, influence, negotiation, and issue-resolution skills.
• Proven ability to lead and develop teams, manage competing priorities, and maintain high standards in a dynamic enterprise environment.
• Strong judgment, attention to detail, and commitment to clear, consistent, accessible, and compliant UM guidance.

Education Bachelor's degree or equivalent relevant professional experience required; advanced degree or specialized training in healthcare administration, clinical operations, business, public health, or a related field preferred.

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: 11/13/2026

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