Manager, Pharmacy Policy Management

Job not on LinkedIn

🔥 0 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $54.3k - $145.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

👻 Ghost score 0%

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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 identification of new and emerging pharmacy policy opportunities across Commercial, Medicare, and Medicaid lines of business • Develop detailed business requirement documents for pharmacy policies • Translate policy intent into claims processing rules, utilization management workflows, and reimbursement methodologies • Support policy enablement processes • Align coding and reimbursement logic with Medical Pharmacy policy intent • Establish quality monitoring programs for Medical Pharmacy policy implementation and operational execution • Lead root cause analyses for policy defects, configuration issues, coding inaccuracies, and operational failures • Ensure audit readiness and maintain supporting documentation • Develop and monitor KPIs supporting Medical Pharmacy policy effectiveness • Use data analytics to identify utilization trends, operational gaps, coding defects, and cost-saving opportunities • Support internal audits, external audits, compliance reviews, and corrective action initiatives • Drive operational excellence, reduce policy-related defects, and improve claim payment accuracy

🎯 Requirements

• 3+ years of policy & business analytics experience • Certified Professional Coder (CPC), Certified Pharmacy Technician (CPhT), or agreement to obtain CPC within one year of hire • Experience partnering with cross-functional stakeholders across clinical, operational, and technical teams • Experience translating data analytics to insights • Knowledge of specialty pharmaceuticals, provider-administered drugs, biosimilars, infusion therapies, and emerging therapeutic categories • Knowledge of Medicare Part B drug management and reimbursement • Experience with specialty drug cost-management programs and affordability initiatives • Knowledge of Payment Integrity and medical drug claim editing platforms • Bachelor’s degree in pharmacy, healthcare administration, or related discipline, or equivalent combination of education and relevant experience

🏖️ 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