At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryThe Medicare Product Implementation department is accountable for ensuring Medicare's mandatory core Part C benefits and supplemental benefits are administered correctly. On occasion, CMS (Centers for Medicare Medicaid Services) requires regulatory changes during the plan year. The Medicare Benefits Standards & Guidance Lead Director ensures accountability for the implementation, management, and maintenance of the Medicare Part C benefits when regulatory changes are required across Medicare including Individual general enrollment, Special Needs Plans (SNP) and Employer Groups.The Medicare Benefits Standards & Guidance Lead Director acts as the point of contact to our corporate partners, such as Benefit & Product Strategy, Benefits & Product claims configuration, Medicare Service Operations (MSO), Medical Policy & Program Solutions (MPPS), Provider Network, and Compliance. This role is primarily responsible for the project management support for implementing mid-year regulatory changes to Medicare benefits and claims system SNOW tickets that are misaligned to strategic intent.As the Medicare Benefits Standards & Guidance Lead Director, you will be responsible for creating requirement documentation through partnering with Medicare Benefit & Product Strategy that will clearly describe the benefit intent for claims setup and administration. The requirement documentation will be the primary source of truth for claims setup and policy administration. This role is also responsible for assembling testing scenarios, in collaboration with Product Quality Assurance for QA execution and alignment of CMS (Center for Medicare Medicaid Services) regulatory changes.• Provide strategic direction for Medicare benefit claims processing outcome for Medicare regulation changes and SNOW ticket resolution tying back to strategic intent.
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• Point of contact to Compliance and MSO for Medicare regulation changes to benefits and impacts on Medicare product standards.
• Provide strategic insights and recommendations of Medicare regulation changes in collaboration with the Medicare Benefit and Product Strategy department to ensure compliance.
• Develops and advances a comprehensive implementation strategy aligned with the organization's goals and objectives to successfully enhance the organization's competitive advantage and brand recognition.
• Approves metrics and key performance indicators (KPIs) used to evaluate the product implementation's success and impact while preparing regular reports for management.
• Provide project management to ensure required Medicare regulation changes are implemented, tested and approved by Medicare Benefits and Product Strategy department.
• Provide project management to ensure required changes due to SNOW ticket resolution is implemented, tested and approved by Medicare Benefits and Product Strategy department.
• Ensure the completion of clear and concise benefit intent and member journey as designed by Product Ideation and Strategy are handed over for implementation.
• Collaborate with cross-functional teams to define and document clear and detailed claim requirements, ensuring accurate adjudication and payment processes.
• Facilitate and document deep-dive discussions with strategy and operational partners to close gaps in benefit design necessary for benefit setup.
• Obtain operational partner attestation that benefit design and intent are understood ensuring accurate setup.
• Participate in the review of CMS regulatory changes Business Requirements Documentation (BRD) developed by claims configuration partner to ensure the configuration aligns to benefit intent.
• Responsible for approving assigned BRD intent so that configuration can commence.
• In coordination with Product Implementation leadership, develop a post-production process for continued monitoring of benefit intent alignment by reviewing production reporting and involving escalation protocols to solve claims payment issues and ensuring the correction is completed.
• Participate in building test scenarios and QA sign-off of benefit and policy setup for CMS regulatory changes and SNOW ticket solution.
• Utilize existing benefit source of truth repository and processes to intake and prioritize work and organize requirement documents.
Track and communicate progress.
Required Qualifications• 10 years Medicare Advantage experience in any area such as: product, claims, compliance, or operations.
• Familiarity of Special Needs Plans (SNP) benefits and cost sharing setup.
• Familiarity of the company's core functions i.e., claim processing, provider billing, benefit configuration, ID Cards, provider set up, etc.
• Decision-making, including analysis, creativity, collaboration, and leadership skills.
• 6+ years related cross-functional, project management experience.
• Must demonstrate strong project management skills: multi-tasking priorities and facilitating/executing multiple projects.
• Highly organized and detailed oriented with proof-reading and quality control skills.
• Excellent analytical skills.
• Proven record of accomplishment of delivery results.
• Strong written and verbal communication skills.
• Strong interpersonal skills and the ability to work independently and lead in a team environment. Proven ability to collaborate across boundaries.Preferred Qualifications
- 10 years' hands-on experience in Medicare benefit development, benefit verification, benefit implementation, claims configuration, claims processing or benefit/clinical policy.
- Lead multiple team leaders on complex initiatives
- Intermediate knowledge of the company's core functions i.e., claim processing, provider billing, benefit configuration, ID Cards, provider set up, etc.
- PMP (Project Management Professional) or Six Sigma Certification i.e., Lean or Green Belt.
• Bachelor's degree or equivalent experiencePay Range
The typical pay range for this role is:$100,000.00 - $231,540.00
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 peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.