Senior Manager, Project Program Management (Claim Operations)

CVS Health•Hartford, CT

1d•$82,940 - $182,549

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. This individual contributor position A. Designs, develops, and leads the Aetna Business Unit Claim Operations Review program, providing 1) ongoing assessments of the health of end-to-end claim operational and financial flows, 2) analysis of operational issues, and 3) insight into factors in the operational environment that could affect the actuarial reserve setting process. B. Leads and oversees the construction of analysis and presentation deck by members of the Claim Operations Analytics team; Presents the materials during the twice-monthly Operations Review Calls C. Designs, conducts, or leads ad hoc operational analysis to meet Service Operations information needs D. Maintains various routine reports and information sources supporting Commercial and Medicare Service Operations constituents

Requirements

In-depth understanding of the medical/dental claim operational lifecycle including: Provider Billing/coding process, Claim Intake & Distribution, Pre-adjudication process, Claim editing, Pended Claim Inventory management, Auto-adjudication, Payment Process, Appeals, and Rework.
Demonstrated understanding of actuarial reserving concepts and the interaction between claim operations and reserve modeling.
5 years’ experience designing appropriate metrics and conducting “large population” (100K+) claim analyses to monitor and evaluate the quality and speed of operational flows through claim lifecycle phases.
5 years’ experience developing and delivering professional analytical presentations to senior leaders.
Demonstrated adaptability to changing operational conditions, including development of innovative approaches for understanding the impact of an evolving operational environment.
Demonstrated experience in peer leadership: leading others through influence, rather than through formal organization authority.
MS Excel power-user.
3 years' SQL, SAS, GCP or related query-construction experience.

Nice To Haves

3+ years’ experience with Aetna claim systems and operational environment.
3+ years’ hands-on experience querying large-scale raw operational claim data sets, including data cleaning and conditioning.

Responsibilities

Designs, develops, and leads the Aetna Business Unit Claim Operations Review program, providing ongoing assessments of the health of end-to-end claim operational and financial flows, analysis of operational issues, and insight into factors in the operational environment that could affect the actuarial reserve setting process.
Leads and oversees the construction of analysis and presentation deck by members of the Claim Operations Analytics team; Presents the materials during the twice-monthly Operations Review Calls.
Designs, conducts, or leads ad hoc operational analysis to meet Service Operations information needs.
Maintains various routine reports and information sources supporting Commercial and Medicare Service Operations constituents.