Sr Analyst, Pharmacy Network Operations Managed Care

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

CVS Health is on a mission to transform healthcare. With a shared purpose to help people on their path to better health, we are finding new ways to care for our communities, leveraging our brick and mortar footprint of 9,000+ stores.  At the heart of this strategy are the 180,000+ store colleagues who build unmatched human connections with our customers every day.  As we, seek to simplify a complex healthcare system for the patients we serve, while delivering disruptive innovation at a rapid pace, thoughtful communications that engage, inspire, and activate our colleagues across multiple channels are increasingly essential. 

As a member of the Adjudication Performance team you will be responsible for facilitating effective solutions related to the adjudication and processing of pharmacy and medical claims and newly expanded healthcare services. Create and ensure custom solutions are implemented and tested according to requirements, support optimization of the existing vendor product portfolio and new product development—enabling data-driven strategic decision-making to identify new revenue opportunities.

You will be responsible for assessing current portfolio of products, connecting to standard adjudication services, with focus on performance, reliability, and parity.  Identify and create custom solutions to support and meet on going business needs.  Provide comprehensive reporting and key performance metrics for reconciliation, revenue cycle, and adjudication/claims processes analysis.

Facilitate effective solutions related to adjudication and processing of pharmacy and vaccine/medical claims, maintaining current services, support optimalization of existing vendor product portfolio, provide continual evaluation of processes and procedures to assist in new product development, create business cases from data driven strategic decision making to identify revenue risk and new revenue opportunities.

Assist in building, testing/deploying solutions and updates to relevant solutions, complete within specified timelines and monitor performance, outcomes and reporting to ensure proper functionality and de-collisioning when needed. The Sr Analyst will work cross functionally with both internal and external partners to inform, influence, and support design solutions, technology, tools and processes that simplify billing of products/services, remove friction from the system, thereby enabling access to care for our patients, simplifying process for our colleagues and delivering value to the enterprise.

The position requires strong analytical skills, communication, collaboration and be a subject matter expert to be able to guide and influence internal and external business partners.  This role will also be responsible for review and resolution for incidents reported through the Store Support center related to claim transactions, initiatives, and to support our store colleagues.

The Retail Adjudication Solutions Sr Analyst will work cross functionally with both and external partners to inform, influence, and recommend solutions, tools and processes that simplify products/services to remove friction from the system, whereby enabling access to care for our patients, simplifying processes for our colleagues and delivering value to the enterprise. This role will play an integral part of driving operational efficiencies, solutions and compliance for the enterprise.

Primary Responsibilities

Delivers Results

• Continually evaluates product performance against KPIs and identify opportunities for improvement to Senior Manager based on performance
• Perform data analysis on new/existing solution to discover new opportunities, identify pain points and monitor key processes for implemented solutions.
• Optimizes and level set expectations with stakeholders by partnering closely with Store Operations, Network Operations, Payer Relations and Retail Field Leadership, to ensure appropriate levels of support and collaboration
• Work cross-functionally with CSC partners to develop solutions  and action plans to mitigate identified risks and opportunities tailored to the specific needs of pharmacy business unit, as needed.
• Development of billing/vendor solutions that enable business growth/ne