Manager Pharmacist, Pharmacy Appeals

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

The Manager Pharmacist, Pharmacy Appeals 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 managing the Department of Insurance (DOI) team, reviewing and resolving MAC appeals, 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 Pharmacist, Pharmacy Appeals is also responsible for managing the team resolving the Department of Insurance (DOI) request, creating reports required to monitor 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 people-leader collaborating with internal business units and various States as needed 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.

What you will do

• Manage the Pricing Department of Insurance (DOI) team

• Review and resolve MAC appeals

• Leads with strategic leadership and guidance, 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 support 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.

• 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.

Required Qualifications

• 5+ years’ experience with all Pharmacy and state department of insurance appeal related processes and state regulations, and claims adjudication, including claims adjudication logic

• 3+ years of people leadership

• Ability to work under tight deadlines

• Excellent Communication, interpreting, writing and leadership skills

• Ability to prioritize, organize, and manage DOI requests

Preferred Qualifications

• Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal

• Adjudication system experience

• Strong mathematical problem-solving skills

• Prior PBM Knowledge

• Familiarity with wholesaler invoices

Education

• Bachelor’s / Pharm D degree in Pharmacy

• Current Pharmacist License in good standing, based on applicable state licensing requirements.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$123,250.00 - $228,800.00

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 t