Health Services Manager, Evaluation & Management Policy Management

Job not on LinkedIn

🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $60.3k - $132.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Lead the work and deliverables of multiple complex programs and support business initiatives impacting multiple processes, systems, functions and products • Identify and validate appropriate medical, coding, reimbursement and pre-payment policies for each request • Ensure deviation recommendations align with policy intent, clinical guidelines, contractual obligations and regulatory requirements • Conduct quality reviews to validate policy alignment, decision accuracy, documentation integrity and governance compliance • Perform periodic audits and implementation reviews to verify approved deviations are operationalized accurately • Develop reporting and performance metrics related to deviation volumes, turnaround times, approval outcomes and quality performance • Analyze deviation trends, appeals, quality findings and recurring exception requests to identify opportunities for policy clarification and process improvement • Lead initiatives focused on improving review consistency and strengthening controls • Collaborate and partner with functional managers and other business areas across segments • Develop and implement innovative ideas supporting work and teams • Assist others in identifying solutions to issues negatively impacting program or project plans • Convert technical findings and complex data visualizations into clear, actionable business strategies

🎯 Requirements

• 5+ years of medical, payment or clinical policy experience • Certified Professional Coder (e.g., CPC, CCS, RHIT) • Experience with business analytics focused on data analysis for decision-making • Proficiency in Microsoft Excel, Word, PowerPoint, Tableau and Power BI • Ability to work independently, think creatively, and proactively identify process improvement and automation opportunities • Exceptional written and verbal communication skills • Demonstrated organizational and prioritization abilities • Effective problem-solving and sound decision-making skills • Bachelor's degree or equivalent experience • If candidate has an associate’s degree, an additional 2 years of experience is needed • If candidate has no degree, an additional 4 years of experience is needed • Preferred: Certified Evaluation and Management Coder (CEMC) • Preferred: Familiarity or experience with Evaluation and Management • Preferred: Familiarity with AMA CPT/HCPCS codes, ICD-10 Codes, Medicare Policies and NCD/LCD’s • Preferred: Code editing and quality review experience related to payment policies, projects, and programs • Preferred: QuickBase applications • Preferred: Project management

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility