Senior Manager, Corporate Compliance - Risk Adjustment

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

As a Senior Manager, Medicare Compliance – Risk Adjustment, you are responsible for overseeing and maintaining compliance with CMS regulations related to Medicare Advantage Risk Adjustment, Hierarchical Condition Categories (HCCs), encounter data submission, documentation and coding compliance, and related regulatory requirements. This position serves as a key compliance leader and subject matter expert, partnering with Risk Adjustment Operations, Coding, Provider Education, Clinical Documentation Improvement (CDI), Internal Audit, Legal, and Government Affairs teams to ensure organizational adherence to CMS requirements.

The ideal candidate possesses extensive experience in Medicare Advantage compliance and a deep understanding of CMS Risk Adjustment methodologies, diagnosis coding requirements, medical record documentation standards, RADV audits, and evolving regulatory guidance.

Key Responsibilities

• Lead the Medicare Advantage Risk Adjustment compliance program.

• Monitor and interpret CMS regulations, HPMS memoranda, Final Rules, Medicare Managed Care Manual guidance, RADV requirements, and OIG enforcement activities.

• Assess operational processes for compliance risks related to risk adjustment activities.

• Develop and implement corrective action plans for identified compliance issues.

• Conduct compliance risk assessments related to coding, documentation, and encounter data submissions.

Required Qualifications

• Minimum 7 years of experience in Medicare Advantage, Risk Adjustment, Coding Compliance, Audit, or Regulatory Compliance

• Minimum 5 years in a leadership role

• One or more of the following certifications: CPMA (Certified Professional Medical Auditor), CRC (Certified Risk Adjustment Coder), CPC (Certified Professional Coder), CCS (Certified Coding Specialist)

• Willingness to travel up to 10% (including by plane)

Preferred Qualifications

• Health Information Management (RHIA/RHIT)

• Nursing – Strong understanding of clinical documentation and medical record review

• Certified Risk Adjustment Coder (CRC) with compliance experience

• Provider coding audit/compliance leadership experience

• Medicare Advantage compliance leadership experience supporting RADV, HCC validation, and CMS audits

Education

Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, Public Health, Business Administration, Healthcare Compliance, or a related healthcare field required; equivalent years of work experience may substitue.

Pay Range

The typical pay range for this role is:

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. 
 

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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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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