Executive Director, CGSO Quality and Audit Center of ...

Job DescriptionAs the Executive Director, Clinical and Government Services Operations (CGSO) Quality and Audit Center of Excellence, the leader will be responsible for the leadership of approximately 200 colleagues and direct reports include 4-5 direct reports, including Directors, Sr Managers, and Managers. This leadership role will lead a diverse team that supports an accurate and compliant prior authorization process and continuous improvement within the following areas: Commercial/Exchange, Medicaid, Specialty Guideline Management (SGM), Medicare D Coverage Determinations, Medicare B Org Determinations, and Appeals. In addition to supporting the prior authorization process, this role is also responsible for the quality monitoring, continuous improvement and reporting for Pharmacy Advisor (RxAdv) and Medication Therapy Counseling (MTC)/Medication Therapy Management (MTM). This leader is responsible for highly regulated and visible functional support and eliminating risk of over $250M in Performance Guarantees across the PBM and various Health Plan, Employer and TPA clients including leadership of the Quality Monitoring/Controls, Audit and Regulatory Support for all lines of business, and driving Continuous Improvement efforts across the CGSO organization: Quality Monitoring and Controls performs post completion and targeted reviews of work products to identify and remediate risk in real-time and to provide performance management capabilities for the Operations teams. This team supports Clinical PA and Appeals, Medicare CD, OD, and Appeals, and the Clinical Consultative Operations teams (RxAdv, MTC, and MTM) delegated to the PBM for many Health Plan, Employer and TPA clients as well as the Aetna Health Plan. Audit and Regulatory Support supports all Audit work and Regulatory changes. Clinical and Government Services Operations average 50+ audits annually including Internal Audits, CMS Program audits, client mock audits, State audits, delegation audits, and NCQA/URAC accreditation audits. This focused team supports universe completion and QA, prep work to identify risks, presentation during audits, and any required impact analysis or corrective action planning. Training Center of Excellence coordinates training activities for new hires through collaboration with internal partners, including Welcome Season ramp planning, as well as design/maintenance of operational Work Instructions and training documentation for Clinical and Government Services Operations users, including clients and used as artifacts in audits. Continuous Improvement leadership will include root cause analysis of highly complex and interconnected member experience issues as well as development of action plans to support resolution. The team will drive continuous improvement and change management efforts within the department as a subject-matter expert in regulatory guidance and will need to be able to have critical thinking skills to problem solve/root cause complex clinical and operational priorities and propose possible enterprise solutions.Primary Duties and Responsibilities; 1. Lead and manage risk of Clinical and Government Services delegated services to prevent CMS, state and accreditation corrective actions, penalties, and/or performance guarantee payouts2. Represent Vice President and Clinical and Government Services Operations during any audit activity with both internal and external parties including regulators and clients 3. Build and lead a continuous improvement team that will include root cause analysis of highly complex and interconnected member experience issues as well as development of action plans to support resolution4. Develop a high performing team and pipeline of talent to deepen PBM leadership bench5. Prepare for Welcome Season and work with internal and external partners to implement regulatory changes through the submission of system enhancements needed and/or operational process changes where appropriate to meet required client and/or regulatory requirementsRequired Qualifications15+ Years of related work experience 10+ years of experience in a healthcare clinical operations leadership role, delivering results while building high performing teams. 5+ years of experience in pharmacy, pharmacy management, formulary management, drug utilization, managed care pharmacy, pharmacy benefit management, or third party (benefit) administration Process Discipline: The ability to establish and manage repeatable processes to efficiently drive accurate, consistent results Results Orientation: Ability to keep colleagues and the organization focused on results and consistently willing to hold self and others accountable for results. Team Leadership: Highly developed leadership skills to build high-performing teams, manage and develop talent, influence and impact a broad set of stakeholders, engage and inspire others, and lead by example. Powerful Communication: The ability to communicate effectively and succinctly with a diverse range of constituents, both verbally and on paper, and with all levels of an organization. Structured & Logical Thinking: The ability to identify and define business problems and issues, and develop strategic, analytical, and financial frameworks to conduct analysis and/or measure success. Ability to proactively identify potential problems and risks and develop solutions and mitigation plans. Rigor in team and self-evaluation: Highest level of attention to detail. Ability to measure the organization's performance with the highest degree of rigor against measurable goals. Intellectual Curiosity and Tenacity: Ability and willingness to learn on the fly to understand and solve complex problems. Independence and Autonomy: Well organized, autonomous individual who can set direction and priorities, deliver results, make sound business decisions, and lead others without prompting or direction from leaders. Ability to Partner Effectively: Effectively interact with peers and other personnel at all levels of an organization to positively impact joint activities, projects or events; utilize active listening skills and develop rapport with internal and external customers. Passion for Health Care: A history of work in the health care industry and an ongoing desire to make one of the world's strongest health care companies even strongerCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- Previous experience within Health Care Pharmacy Benefit Management (PBM); especially within Government Services.- Knowledge of the Software Development Life Cycle.- Experience in the design and implementation of technology solutions and automation.EducationBachelor's Degree or equivalent work experience required. Master's Degree preferred RPh License preferredBusiness OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15