Sr. Manager, Pricing - Pharmacy Appeals

CVS Health

8d•$67,900 - $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. Position Summary The Senior Manager, Pricing will lead a team colleagues and contractors in the management of specific functions related pharmacy reimbursement appeals including the Service Warranty process as well as supporting the Department of Insurance and Secondary Appeals operations. In this role, you will ensure the appeals are executed under tight Turnaround Times (TATs) and with high accuracy while making sure the team is appropriately staffed and organized. In addition, you will be responsible for developing and implementing solutions individually and being a lead working with partners to improve and automate processes to increase productivity and fulfill state regulatory changes. You will be leading and coaching the appeal team coordinators as well as guiding other internal business units to resolve issues quickly. The Senior Manager, Pricing is also responsible for working legal and compliance team to ensure state regulatory updates are operationalized. This role requires a thorough knowledge of claim adjudication, appeals related processes, and being a leader working with other internal business units to develop new solutions to meet the ever-increasing number of complex appeal bill compliance requirements. The position will be responsible for quality control process to ensure compliance.

Requirements

7 year’s experience in pricing, PBM/healthcare operations, process improvement, quality, analytics, or related domains
5+ years directly leading operations teams
1+ years’ experience with pharmacy appeal related processes and state regulations, and claims adjudication, including claims adjudication logic

Nice To Haves

Excellent leadership skills
Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal
Ability to work under tight deadlines
Strong mathematical problem-solving skills
Prior PBM Knowledge
Familiarity with wholesaler invoices

Responsibilities

Leads with strategic leadership and guidance to pharmacy reimbursement appeals teams, ensuring effective strategies and operations are effectively progressed to improve performance.
Oversees pharmacy appeals service warranty process to ensure timely processing and compliance with state regulations
Reviews and responds to complex inquiries related to pharmacy reimbursement appeals submitted by state regulators and pharmacies.
Analyzes market trends, and competitive insights to generate actionable recommendations.
Collaborates cross-functionally with legal, finance, and account teams to align client strategies with business goals, enhance value propositions, and optimize appeals services.
Influences stakeholders through effective communication and negotiation, leveraging operations expertise and industry knowledge to establish mutually beneficial partnerships and agreements.
Applies experienced-based pharmacy claims and appeals knowledge and insights to influence strategic decision-making.
Counsels and mentors team members, providing guidance and support to enhance their skills and professional development.