Lead Director - UM Center of Excellence

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
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.

…