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Position Summary
The Manager, Pricing must have expertise and knowledge of the Pharmacy claims appeal process and the various applications used in the appeal process to comply with state bill requirements. In this role, you will be responsible for developing and implementing solutions individually, and being a lead working with IT to automate solutions for complex requirements unique to states with pharmacy bills. This also includes being the appeals team SME in understanding the impact of appeal related issues and resolving them under tight TATs to remain in compliance. The Manager, Pricing is also responsible for creating reports required to monitor appeal bill compliance, satisfying client reporting requirements for appeals, as well as developing and ensuring the accuracy of appeal reporting as required by state agencies. This role requires a thorough knowledge of claim adjudication in order to perform research , internal claim related processes, and being a leader working with other internal business units to develop new solutions to meet the ever-increasing number of complex pharmacy bill compliance requirements. The position will be responsible for quality control process to ensure compliance.
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What you will do
- Leads with strategic leadership and guidance to pricing teams, ensuring effective response to pharmacy and state department of insurance (DOI) appeals are effectively reviewed and responded.
- Partner with legal to disposition pharmacy complaints and appeals that come through state agencies
- Leads and owns the process and work instruction documents that comply with state laws and meets CVS compliance
- Leads and participate in state appeals audit and exam. Provides the information to state DOI on the inquiries.
- Interprets and drafts responses to state DOI inquiries and works with CVS legal team to respond to inquiries.
- Collaborates cross-functionally with legal, compliance, network and other teams to manage the pricing appeals.
- Influences stakeholders through effective communication and negotiation, leveraging pricing expertise and industry knowledge to establish mutually beneficial partnerships and agreements.
- Networks with industry professionals through attending events and conferences related to company objectives, and participating in industry forums, monitoring emerging trends, and keeping updated on critical regulatory changes, ultimately improving innovation and maintaining industry leadership
- Counsels and mentor pricing team members, providing guidance and support to enhance their pricing skills and professional development.
- Delivers pricing solutions and recommendations that drive profitability and revenue optimization and contribute to the overall financial success of the organization.
- 5+ years relevant work experience
- 1+ years' experience with all Pharmacy and state department of insurance appeal related processes and state regulations, and claims adjudication, including claims adjudication logic
- Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal
- Adjudication system experience
- Strong mathematical problem-solving skills
- Prior PBM Knowledge
- Familiarity with wholesaler invoices
- Ability to work under tight deadlines
- Excellent Communication, interpreting, writing and leadership skills
- Ability to prioritize, organize, and manage DOI requests
Bachelor's Degree or relevant experience required.
Pay Range
The typical pay range for this role is:
$54,300.00 - $159,120.00
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.
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.
For more detailed information on available benefits, please visit Benefits | CVS Health
We anticipate the application window for this opening will close on: 04/30/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.