Senior Director, Coverage Review Client Operations Evernorth Health Services (Hybrid)

The Senior Director Coverage Review Client Operations is an enterprise leadership role accountable for setting the strategic direction operational standards and regulatory integrity of Coverage Review clientfacing operations across Evernorth / Cigna Healthcare. This role provides executive ownership of complex highly regulated operational capabilities that directly support Account Management and external clients with a strong emphasis on Medicare programs appeals and reconsiderations Independent Review Entity (IRE) support Coverage Review implementations and Prior Authorization (PA) research.

Operating at an enterprise level this leader translates regulatory client and market requirements into scalable operating models that balance compliance service excellence and operational efficiency. The Senior Director serves as an accountable executive partner to Account Management Compliance Clinical Legal Product and Technology leaders ensuring consistent execution audit readiness and a differentiated client experience across multiple lines of business.

Scope & Impact

• Executive ownership of enterprise Coverage Review Client Operations supporting a diverse portfolio of commercial and government clients across multiple markets and lines of business.

• Direct accountability for Medicarerelated operational support including appeals reconsiderations and IRE support where accuracy timeliness and compliance carry significant regulatory financial and reputational risk.

• Authority to define and standardize operating models governance and controls for clientfacing Coverage Review functions.

• Leadership of multiple operational functions and senior leaders with responsibility for longterm scalability organizational continuity and leadership bench strength.

• Highvisibility role with regular engagement with senior executives Account Management leadership compliance partners and external clients including audit and escalation scenarios.

Key Responsibilities

1. Client Operations & Account Management Partnership

• Serve as the accountable executive leader for Coverage Review Client Operations supporting Account Management and client delivery models.

• Establish enterprise standards for clientfacing operational performance escalation management and issue prevention.

• Translate client regulatory and market needs into enterprise operational strategies and multiyear roadmaps.

2. Regulatory Medicare & IRE Oversight

• Maintain endtoend operational compliance with federal and state regulatory requirements with deep focus on Medicare and CMS standards.

• Provide executive oversight of Medicare coverage review activities including appeals reconsiderations and Independent Review Entity (IRE) support.

• Define governance controls and monitoring frameworks to ensure audit readiness risk mitigation and sustained compliance.

3. Coverage Review Enablement & Enterprise Integration

• Oversee Coverage Review implementations for new and existing clients ensuring operational readiness compliant configuration and crossfunctional alignment.

• Lead PA research and related enablement functions to support consistent evidencebased and policyaligned decisionmaking at scale.

• Partner with Product Technology and Clinical leaders to operationalize new capabilities regulatory changes and enterprise initiatives.

4. Operational Performance Financial Stewardship & People Leadership

• Drive operational excellence through performance management KPI oversight continuous improvement and sustainable operating models.

• Balance compliance service quality and cost efficiency to support longterm business performance and client outcomes.

• Lead and develop a multilayer leadership team building accountability succession readiness and future enterprise leaders.

• Communicate complex operational regulatory and risk topics effectively to executives partners and clients.

Qualifications

• Bachelors degree required; advanced degree (MBA MHA MPH PharmD or similar) preferred.

• 12 years of progressive experience in healthcare operations coverage review prior authorization or related payer functions including leadership roles within large complex and highly regulated organizations.

• Deep expertise in Medicare coverage review appeals and Independent Review Entity (IRE) processes with strong knowledge of CMS and broader regulatory requirements.

• Demonstrated ability to partner with Account Management and lead clientfacing operational models in regulated environments.

• Proven success leading enterprise implementations operational transformations and continuous improvement initiatives.

• Executive presence with strong written and verbal communication skills and the ability to influence decisionmaking across a matrixed enterprise.

• Strong analytical judgment and decisionmaking capability in ambiguous highrisk and highvisibility environments.

• Experience supporting PBM utilization management or prior authorization operations and partnering with Product and Technology teams to operationalize new capabilities.

About The Cigna Group

Qualified applicants will be considered without regard to race color age disability sex childbirth (including pregnancy) or related medical conditions including but not limited to lactation sexual orientation gender identity or expression veteran or military status religion national origin ancestry marital or familial status genetic information status with regard to public assistance citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

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The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama Alaska Arizona Arkansas Delaware Florida Georgia Hawaii Idaho Iowa Kansas Maryland Massachusetts Michigan Nebraska Ohio Pennsylvania Texas Utah Vermont and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal state and local ordinances.