Lead Director - UM Center of Excellence

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.

Responsibilities

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; 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; 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; Provide consultation on system enhancements and operational changes that affect UM workflows; Establish and monitor performance measures for governance effectiveness; Use data and stakeholder feedback to identify content gaps, simplify and standardize guidance, 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; Lead post-publication monitoring and continuous improvement; 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

Requirements

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; Bachelor's degree or equivalent relevant professional experience required

Nice to have

Advanced degree or specialized training in healthcare administration, clinical operations, business, public health, or a related field

Benefits

Medical, dental, and vision coverage; Paid time off; Retirement savings options; Wellness programs; Other resources based on eligibility; Eligibility for CVS Health bonus, commission or short-term incentive program; Award target in the company's equity award program