Manager, Pricing

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Position Summary

The Manager, Pricing 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 for 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.  You will be leading and coaching the appeal team coordinators as well as guiding other internal business units to resolve issues quickly.  The Manager, Pricing is also responsible for creating reports required to monitor appeal bill 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, internal claim related processes, and being a leader working with other internal business units 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

• Leads with strategic leadership and guidance to pricing teams, ensuring effective response to pharmacy and state department of insurance (DOI) appeals are effectively reviewed and responded.
• Leads and drive the pharmacy portal enhancements with IT team and other stakeholders.
• 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 the state DOI inquiries and work with CVS legal team to respond the inquiries.
• Collaborates cross-functionally with legal, compliance, network and other teams to manage the pricing appeals.
• Influences stakeholders through effective communication and negotiation, leveraging pricing expertise and industry knowledge to establish mutually beneficial partnerships and agreements.
• Networks with industry professionals through attending events and conferences related to company objectives, and participating in industry forums, monitoring emerging trends, and keeping updated on critical regulatory changes, ultimately improving innovation and maintaining industry leadership
• 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 relevant work experience
• 1+ years’ experience with all Pharmacy and state department of insurance appeal related processes and state regulations, and claims adjudication, including claims adjudication logic

Preferred Qualifications

• 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
• Excellent Communication, interpreting, writing and leadership skills

Education

Bachelor’s Degree or relevant experience required.

Pay Range

The typical pay range for this role is:

$54,300.00 - $159,120.00

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 additi