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 client‑facing 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 Medicare‑related 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 client‑facing Coverage Review functions.

• Leadership of multiple operational functions and senior leaders, with responsibility for long‑term scalability, organizational continuity, and leadership bench strength.

• High‑visibility 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 client‑facing operational performance, escalation management, and issue prevention.

• Translate client, regulatory, and market needs into enterprise operational strategies and multi‑year roadmaps.

2. Regulatory, Medicare & IRE Oversight

• Maintain end‑to‑end 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 cross‑functional alignment.

• Lead PA research and related enablement functions to support consistent, evidence‑based, and policy‑aligned decision‑making 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 long‑term business performance and client outcomes.

• Lead and develop a multi‑layer leadership team, building accountability, succession readiness, and future enterprise leaders.

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

Qualifications

• Bachelor’s 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 M