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Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

As a Healthcare Compliance Senior Analyst, you will ensure contractual and regulatory compliance as it relates to third party programs. You will act as a liaison between internal departments and external contacts such as health plans, processors, pharmacy benefit managers (PBM), and governmental agencies. Additionally, you will facilitate the initiation and on-going maintenance of pharmacy system to ensure that CVS pharmacies are able to service and bill prescriptions for patients of third-party programs, where CVS is contracted and/or enrolled.

Responsibilities:

Third Party Information Management

• Make informed decisions by thoroughly reviewing communications distributed by PBMs, processors, health plans, state Medicaid and Medicare, relative to prescription and/or medical claim processing

• Serve as a subject matter expert for both internal and external representatives by researching prescription insurance program requirements, medical billing policies, compliance inquiries, and related issues/complaints, and crafting timely responses

• Demonstrate care by proactively identifying and resolving potential Third-Party operational issues

• Understand the terms of Payer contracts, and NCPDP Standards, to ensure CVS and plan compliance

• Translate, and clarify where needed, payer information and communicate to appropriate internal personnel, field management, and CVS pharmacy locations

• Compose third party articles for the Payer Relations Weekly Update, issue emergency communications via the pharmacy HUB, and post Medicaid related third party program requirements on the Intranet, as necessary

Relationship Building

• Foster and maintain a professional effective working relationship with contracted agencies, PBMs, and health plans

• Problem solving point of contact for complaints and inquiries received from payers on behalf of our mutual customers

• Collaborate with payers, internal departments, and field personnel, to implement process improvements for prescription and/or medical claim processing, to ensure program compliance and to enhance store level customer service

• Keep Payer Relations Contracting Directors and/or appropriate management apprised of problematic Payer related issues that may significantly impact prescription processing

Plan Code Facilitation

• Evaluate third party information to determine if an internal system update is required

• Track plan changes via database, and prepare necessary documentation to facilitate new third-party plan codes and/or updates to existing codes

• Collaborate with appropriate internal Payer Relations team(s) to determine best approach for system updates, when needed

Team Work

• Focus on the customer by addressing prescription processing escalations received from various internal departments and pharmacy teams

• Contribute to a high-performing team by looking for opportunities to achieve individual and broader team goals, while remaining flexible for changing business needs, to enable supportive, collaborative, and management of challenging work

• Assist with implementation of procedures, policies, and other projects as needed, to develop processes for efficient day to day payer and customer support

Our ideal candidate is someone who has excellent verbal and written communication skills, has a strong attention to detail with flawless execution, thinks independently and can offer solutions. We also look for someone with professionalism, the ability to problem solve, multi-task, excellent organizational skills, how-to prioritize their book of business and a proven ability to collaborate with both internal and external representatives

Required Qualifications

3+ years of experience in the pharmacy industry with knowledge of standard contract terms and conditions, best practices, and business policies​

Preferred Qualifications

• Knowledge of Pharmacy Benefit Management is a plus

• Bachelor's Degree preferred

• Demonstrated ability to think strategically, act tactically, and deliver outcomes

• Organized and detail-oriented, with the ability to manage multiple tasks simultaneously and adjust priorities as needed, demonstrating high level of independent judgment and proactivity

• Self-starter with strong interpersonal and leadership skills. Demonstrated ability to effectively influence other business areas in a matrixed complex organization

Education

High School Diploma or Equivalent work experience

Pay Range

The typical pay range for this role is:

$46,988.00 - $112,200.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 10/31/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.