Manager, Pricing

CVS Health

5d

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 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.

Requirements

• 5+ years relevant work experience in finance, pricing, legal, pharmacy or similar discipline
• 1+ years’ experience with all Pharmacy and state department of insurance appeal related processes and state regulations, and claims adjudication, including claims adjudication logic

Nice To Haves

• 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

Responsibilities

• 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.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager