Analyst, Network Management
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This role offers an exciting opportunity to join CVS Caremark’s specialized Pharmacy Audit division as a Medicare Pharmacy Claims Auditor. In this position, you will administer assigned Medicare Part D compliance audit programs, conduct detailed reviews of pharmacy-submitted claims, and make independent, data-driven decisions. You will engage directly with network pharmacies to validate claim information, communicate audit requirements, and ensure adherence to CMS and CVS Health standards. Collaboration is essential, as you will partner with fellow auditors and cross-functional teams to successfully execute audit initiatives. The ideal candidate is highly motivated, detail-oriented, and possesses strong communication and time management skills. You will develop subject matter expertise in CVS Health Medicare Audit Programs and take ownership of designated program processes. This role also provides opportunities to innovate—designing tools, improving workflows, and contributing to solutions that enhance audit efficiency and effectiveness. Your work will directly support CVS Health’s compliance with CMS regulations and help maintain strong Medicare STAR ratings.
Requirements
- High School Diploma or GED required.
Nice To Haves
- 1+ years of experience in a pharmacy or Pharmacy Benefit Management (PBM) environment (5+ years preferred).
- 2+ years of experience with pharmacy claims processing systems.
- Working knowledge of CMS Medicare Part D compliance regulations.
- Advanced technical skills, including Microsoft Excel, Access, and SQL.
- Pharmacy Technician Certification Board (PTCB) certification preferred.
Responsibilities
- Conduct outbound calls to network pharmacies to verify claim information
- Distribute audit requests and documentation requirements to pharmacies
- Review prescriptions and supporting documents to ensure compliance with CMS and CVS Health contractual requirements
- Analyze incoming pharmacy documentation and accurately enter data into internal audit systems
- Respond to pharmacy inquiries related to Medicare audit programs
- Track and report progress on assigned audit activities
- Collaborate with internal stakeholders to align on audit objectives and business priorities
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
