Senior Manager, Medicare Compliance - FDR Oversight Program
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Position Summary
As a Senior Manager of Medicare Compliance - FDR Oversight Program, you are an experienced, career level compliance professional responsible for the end-to-end execution and ongoing effectiveness of Medicare First Tier, Downstream, and Related (FDR) compliance oversight. This role will allow you to apply advanced regulatory, analytical, and communication skills to prevent, detect, and mitigate compliance risks while promoting ethical business practices in alignment with CMS requirements.
In this role, you will independently lead compliance initiatives across delegated functions within a complex, matrixed Medicare Advantage environment. You’ll operate with a high degree of autonomy, exercising independent judgment in risk assessment, issue escalation, and oversight of corrective action plans. Partnering closely with Compliance peers and key business stakeholders, you will assess program effectiveness, proactively address emerging risks, and drive continuous improvement.
To Be Successful In This Role, You Will Need
- Strong knowledge of Medicare compliance requirements, including CMS Organization Determination, Appeals and Grievances (ODAG).
- Ability to independently assess risk and recommend effective remediation using analytical and critical thinking skills.
- Experience leading auditing, monitoring, validation, and corrective action oversight activities.
- Clear, effective communication with stakeholders at all levels, including senior leadership.
- Strong execution, prioritization, and time management skills in a fast paced, matrixed environment.
- Comfort influencing outcomes and driving change without direct authority.
Responsibilities Include
- Execute the Medicare FDR Oversight Program, with primary responsibility for oversight of Organization Determination, Appeals and Grievances (ODAG) delegated functions.
- Provide compliance and operational oversight of delegated organization determination functions, applying clinical knowledge and judgment to assess medical management practices, regulatory adherence, and risk mitigation effectiveness.
- Own and execute auditing, monitoring, validation, and corrective action plan (CAP) oversight activities aligned within the Medicare Compliance Work Plan.
- Identify, prioritize, and escalate compliance risks; conduct root cause analysis; and support timely, sustainable remediation with internal and external partners.
- Serve as a subject matter expert on Medicare FDR oversight, maintaining current knowledge of CMS guidance, HPMS memos, and contractual requirements.
- Partner with internal stakeholders and delegated entities to strengthen compliance controls and promote consistent, compliant outcomes.
- Utilize compliance tools and systems, including Medicare eGRC platforms (e.g., Archer) and Microsoft applications, to support oversight, documentation, monitoring, and reporting.
- Support broader Medicare Compliance initiatives and projects as assigned.
Required Qualifications
- 7+ years of experience in healthcare, or Medicare Advantage program compliance or regulatory work
- 2+ years of experience independently leading complex compliance, risk, or regulatory initiatives
- Excellent written and verbal communication skills with strong analytical capabilities
- Ability to travel up to 10% (including plane)
Preferred Qualifications
- Prior clinical or operational experience enabling interpretation of medical records, treatment decisions, and clinical documentation (RN, LPN, or similar clinical role/ background preferred)
- Experience administering or overseeing FDR requirements outlined in CMS Compliance Program Guidelines (Chapters 9 and 21)
- Experience supporting CMS Organization Determination, Appeals and Grievances (ODAG) reviews
Education
Bachelor’s Degree; equivalent years of related professional work experience may substitute
Pay Range
The Typical Pay Range For This Role Is
$82,940.00 - $182,549.00
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: 04/22/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
