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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/new healthcare services, working cross-functionally to prioritize, structure timelines, align stakeholders, and incorporate feedback in driving successful outcomes
Strategic Planning
Drive operation excellence for pharmacy/medical billing working with internal and external stakeholders, program development, including initial business case development through launching solutions to our customers and colleagues.
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
Facilitate the distribution of field facing materials with communications partners for key touchpoints
Supports the Senior Manager in developing an effective communication strategy for alerting both internal and external leaders of anticipated changes, partnering with communications teams as needed
Support creating near and longer-term adjudication technology strategic roadmap, taking inputs from multiple sources to influence internal and external stakeholders in the creation of solutions and programs which target emerging healthcare / billing opportunities
Stakeholder Influence and Change Management
Collaborates with cross-functional teams, including Payer Relations, Network Operations, Pharmacy Operations and external vendors and other stakeholders to deliver high-impact solutions
Leverages data, insights, and analytics to influence stakeholders and makes recommendations as appropriate to mitigate risk and improve patient experiences
Be an advocate for our patients and Retail store colleagues, identifying opportunities to reduce patient out-of-pocket expenditure at no cost to the enterprise, promote medication adherence and customer satisfaction
Ad-Hoc Analysis
Supports our pharmacy teams and core business partners utilizing reporting and analysis
Adapt reporting to inform strategies to identify trends communicating those to the right partners as needed.
Translates data insights into meaningful insights and actions
Required Qualifications
3+ years of experience working with NCPDP standards and product implementation
3+ years of experience with pharmacy claims adjudication and NCPDP standards
3+ years engaging and inspiring teams to achieve both short-term, and long-term goals.
3+ years of analytical experience within pharmacy, healthcare, managed care, or related field
3+ years of experience using advanced Excel, PowerPoint skills and other MS Office Applications
Ability to communicate and influence mid-level managers (Director and above), as demonstrated by 3+ years of experience creating and delivering leadership-facing materials and presentations
Preferred Qualifications
5+ years of experience working with NCPDP standards and product implementation
5+ years of experience with pharmacy claims adjudication and NCPDP standards
5+ years engaging and inspiring teams to achieve both short-term, and long-term goals.
5+ years of analytical experience within pharmacy, healthcare, managed care, or related field
5+ years of experience using advanced Excel, PowerPoint skills and other MS Office Applications
Ability to communicate and influence mid-level managers (Director and above), as demonstrated by 5+ years of experience creating and delivering leadership-facing materials and presentations
Experience in Retail Pharmacy
Attention to detail, strong drive to ensure the integrity of underlying data and reports
Proven ability to collaborate with internal and external partners
Ability to make decisions / recommendations under pressure and consistently deliver results on tight timelines
Demonstrated growth mindset and willingness to learn and accept feedback
Proven track record of high performance and ability to multi task
Collaborate cross functionally with leaders and colleagues’ to solution, implement, and drive results.
Strong ability to manage multiple assignments, including those that have competing priorities
Regular and reliable attendance during normal working hours, as established by the leader
Any additional tasks as directed by supervisor or manager
Self-directed individual requiring little direction
Strong interpersonal skills as demonstrated by successful collaboration to achieve shared goals
Strong communication skills in both formal and informal writing and speech
Demonstrating strong attention to detail and follow through with commitments.
Masters degree
Education
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$46,988.00 - $122,400.00
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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 04/07/2025
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.