Senior Manager Project Management Strategic Pricer

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.

Senior Manager Project Management – Contracts and Pricing

Position Summary: 

We are excited to invite a highly motivated and detail-oriented Sr. Manager Project Management to join our team. The Sr. Manager will be part of the Network Platform Solutions – Contracts & Pricing Team, leading the Strategic Pricer team to support Strategic Pricer projects. In this role, you will perform and oversee multiple functions pertaining to Strategic Pricer functionality and enhancements for participating providers. This position offers a valuable opportunity for personal and professional growth, as you will play a key role in successfully delivering and executing enhancements while collaborating with various business partners.

Responsibilities include:

• Primary responsibility is to oversee a team responsible for researching and analyzing Strategic Pricing system functionality and enhancements. It also requires delineation of any other interfacing or manual manipulation altering the price. Validation of theory, when claim reports are furnished from other business areas.
• You also will support the analysis of Aetna’s contract rate tools (SCM Web) to identify operational improvement opportunities/validate a financial comment  is needed, including walk through of the entry guidance when changes are warranted. The candidate must think critically, applying mastery pricing concepts to predict pricing outcomes.
• This role will also provide project support which entails assessing risks both up & down stream, formulating business requirements, working in partnership with our IT counterparts, assembling testing strategies, validating testing results, including review and sign-off during code implementation. This role also includes formulation of training techniques, creation of training materials, and facilitation in partnership with other systems.
• The candidate will also contribute to maintenance/ update of all team training materials, including formulation of contract/claim examples, system mock-ups, and depiction of pricing outcomes. Candidate must be able to explain complex concepts in laymen's terms, as well as furnish visual representations of the concepts.
• Standard Contracted (CNT) and IPA/DOFR (Independent Physician Association/Division of Financial Responsibility) Service Grouping Maintenance and related Billing Code Rules -- at least on a quarterly basis, coordinate with various service grouping content owners, analyze code sets, implement maintenance requests, then audit for accuracy. All Service Grouping code updates ideally will be completed prior to the new service code's effective date.
• Provider Network Contract Analysis Reviews: Evaluate Provider Network requests for new business, as well as conduct comprehensive provider contract analyses prior to renewal or renegotiation, including facilitation of network contract analysis meetings, ensuring thorough compliance with Policies 239 and 264.
• Serve as a subject matter expert for Strategic Pricer. 
• Evaluates combinations of rate drivers and payment methods in the Rate Wizard applying Strategic Pricer concepts, to predict outcomes.
• Research and analyze claim inquiries regarding accuracy of Strategic Pricer and/or identify contract input errors.
• Support other business initiatives and system projects as required.
• Collaborate with cross-functional teams to ensure effective implementation of project objectives.
• Monitor project progress and report on key metrics.
• Facilitate meetings and discussions to gather feedback and drive project improvements.

Required Qualifications:

• 5+ years project management experience
• 5+ years ACAS participating provider claims processing experience
• 5-7 years healthcare insurance experience
• Full understanding of the SCM rate wizard input, non-preferred contracting options, Carve Out & Grouper tabs
• Familiar with Professional Component concept, and EPDB limitations related to same
• Moderate understanding of EPDB & SCSR: Provider & PBG selection logic; fee schedule & modifier pricing logic
• Demonstrated strong understanding of Strategic Pricer logic and concepts
• Excellent verbal and written communication skills

Preferred Qualifications: