Senior Manager – MPPS Policy Consultation

Job not on LinkedIn

🔥 5 minutes ago

🇺🇸 United States – Remote

💵 $67.9k - $182.5k / year

⏰ Full Time

🟠 Senior

👔 Manager

👻 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

• Identify, develop, and execute clinical and payment policies • Ensure policies align with evidence-based guidelines, regulatory requirements, and enterprise affordability goals • Translate clinical and payment policy intent into business requirements for claims processing platforms • Partner with Medical Policy, Medical Coding, Compliance, claims operations, IT, and vendor teams • Define coverage criteria, limitations, exclusions, claims editing logic, coding requirements, and adjudication outcomes • Develop detailed BRDs covering policy intent, coding and clinical logic, claims system behavior, configuration, and testing requirements • Ensure policy implementation across front-end, pre-payment, and post-adjudication processes • Validate behavioral health policies in system logic and medical coding rules • Support testing, defect resolution, and go-live readiness • Perform policy quality assurance and validation • Support audits and remediation by identifying gaps and driving corrective actions • Serve as a clinical and payment policy subject matter expert in governance forums and vendor edit workgroups • Lead the end-to-end policy lifecycle from intake through execution and monitoring

🎯 Requirements

• 7+ years of experience in medical policy, payment policy, correct coding, or clinical practice • Ability to interpret clinical standards and translate them into policy • Knowledge of ICD-10, CPT/HCPCS, and correct coding frameworks • Experience developing Business Requirements Documents (BRDs) for claims system configuration • Strong knowledge of clinical and payment policies and medical necessity criteria management • Experience translating policy into medical coding logic, claims editing, and adjudication rules • Experience with claims adjudication platforms and/or vendor editing solutions • Bachelor’s degree in healthcare or a related field, or work-related experience • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required, or obtained within one year of start date • Ability to work in the United States

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program • Award target in the company’s equity award program • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being