Manager, Pharmacy Adjudication & Affordability

CVS Health•Woonsocket, MA

2d•$66,330 - $145,860•Remote

About The Position

CVS Health is on a mission to transform healthcare by making it more accessible, affordable, and easier to navigate for the patients we serve. As a critical part of this effort, the company is reimagining how prescriptions are processed, priced, and delivered—leveraging its scale, clinical expertise, and 10,000‑store footprint to improve patient outcomes and reduce cost-related barriers to care. The Manager, Adjudication & Affordability plays a pivotal role in translating affordability strategies into real-world prescription processing outcomes. This role sits at the intersection of pharmacy adjudication, patient access, and benefit optimization—leveraging deep expertise in Coordination of Benefits (COB) sequencing, NCPDP standards, and plan design to ensure patients receive the most affordable and appropriate medication pathway available. This Manager will be responsible for designing, executing, and continuously improving adjudication logic and plan sequencing strategies that maximize patient benefits, dynamically adjust for cost drivers, and enable scalable affordability solutions across the CVS ecosystem. The role requires strong analytical rigor and hands-on execution, including active involvement in configuration validation, UAT, and post-launch optimization. Working cross-functionally with Trade, Growth, Payer Relations, IT, Digital, and Pharmacy Operations, this individual will help shape and operationalize innovative affordability solutions—from early-stage ideation through implementation—ensuring they are technically feasible, compliant, and impactful for patients. The ideal candidate brings a deep understanding of pharmacy adjudication and benefit structures, strong problem-solving capability, and the ability to translate complex scenarios into actionable insights. This role demands a highly collaborative operator who can navigate ambiguity, influence partners, and deliver measurable improvements in patient affordability, claim success, and overall pharmacy experience.

Requirements

5–7 years of experience in adjudication, pharmacy operations, PBM operations, healthcare technology, or analytics.
Strong analytical and problem-solving skills.
Experience collaborating across teams and influencing outcomes.
Excellent communication and presentation skills.
Proficiency in Excel and PowerPoint.
Bachelor’s degree or equivalent experience in pharmacy, analytics, or operations.

Nice To Haves

7+ years experience with affordability programs such as coupons or discount card processing or contracting.
Knowledge of pharmacy adjudication or COB processes.
NCPDP membership experience
Experience with UAT, testing, or IT collaboration.
Experience working in cross-functional environments.

Responsibilities

Serve as a subject matter expert in prescription adjudication, with deep expertise in: Coordination of Benefits (COB) sequencing rules, NCPDP standards and transaction logic, Plan design constraints across PBM, retail, and third-party affordability programs
Design, configure, and optimize complex plan sequencing strategies that: Maximize utilization of patient benefits, Adjust dynamically based on patient profile, treatment type, and out-of-pocket cost, Enable the lowest appropriate cost outcome while maintaining compliance
Partner with senior leadership to translate affordability strategies into executable adjudication logic and workflows.
Support the development of curated affordability journeys by ensuring adjudication pathways: Reflect real-world patient scenarios (insured, underinsured, uninsured), Enable effective routing across benefits, coupons, discount cards, and cash options
Continuously evaluate and refine sequencing rules based on: Claims performance and reject patterns, Patient cost outcomes and abandonment signals, Evolving payer rules and market dynamics
Identify, quantify, and prioritize patient affordability opportunities using pharmacy claims and performance data to reduce out-of-pocket costs and cost-related abandonment.
Develop and maintain analytics, reporting, and diagnostic frameworks to monitor: Claim success and reject trends, Affordability pathway performance, Patient out-of-pocket cost exposure
Translate complex adjudication scenarios, plan interactions, and sequencing logic into clear, actionable insights for cross-functional partners and leadership
Support test-and-learn approaches by measuring the impact of new affordability strategies and recommending optimization opportunities.
Partner across Trade, Growth, and Payer Relations to: Inform and shape affordability strategies based on adjudication feasibility and constraints, Evaluate new savings concepts and their applicability within existing plan and regulatory frameworks, Support the design and build of scalable affordability solutions
Collaborate with IT and Digital teams to: Translate affordability and sequencing requirements into detailed system specifications and enhancements, Support development, configuration, and integration of adjudication capabilities across platforms, Ensure solutions are operationally viable and patient-centric
Partner with Pharmacy Operations to align workflows with in-store execution realities and patient experience needs.
Manage multiple concurrent initiatives, balancing priorities, timelines, and interdependencies across stakeholders.
Support end-to-end execution of adjudication and affordability initiatives, including: Requirements refinement, Configuration validation, UAT planning and execution, Defect identification and resolution
Validate that adjudication logic performs as intended across: Primary and secondary benefit routing, Coupon and discount integration, Exception and re-adjudication scenarios
Monitor post-launch performance and: Identify issues impacting cost, claim success, or patient experience, Recommend and implement iterative improvements to sequencing and workflows
Partner with analytics and IT teams to ensure data integrity and consistent performance tracking.
Ensure all affordability and adjudication solutions adhere to: Regulatory requirements, Contractual obligations, NCPDP standards and billing rules
Support appropriate and compliant configuration of adjudication logic and COB sequencing.
Partner with Legal, Compliance, and Payer Relations teams to: Interpret evolving requirements, Assess risks within affordability pathways, Ensure consistency and defensibility of solutions
Contribute to governance processes by documenting logic, decisions, and requirements to support audit readiness and operational transparency.