Manager, Program Management

CVS Health • Louisville, KY

2d

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Brief Overview Facilitates the successful implementation of Medicaid health plan operations programs by coordinating with cross-functional teams. Enhances operational efficiency, ensures compliance with regulatory standards, and contributes to the overall success of healthcare operations. Assists in the management of stakeholder relationships and establishes communication channels to promptly address concerns regarding claims payment, contract or benefit setup. Job Summary Collect, analyze, and interpret operational data to identify trends, patterns, and insights that inform decision-making and drive improvements in operations. Analyze operational issues, incidents, and provider complaints and identify root causes, propose solutions, and collaborate with relevant teams to implement corrective actions, claims payment reconfiguration and prevent recurrence. Apply knowledge of medical coding and billing to ensure accurate and efficient claims processing. Review and analyze complex claim documentation, assess policy coverage and claim validity, collaborate with internal and external stakeholders, and contribute to process improvement initiatives. Identify potential risks and issues that could impact health plan operations success and develop mitigation plans to address them proactively. Ensure that program deliverables meet quality standards and comply with relevant healthcare regulations and best practices. Implement change management strategies to address resistance and ensure smooth transitions during program implementation.

Requirements

• 5+ years in healthcare operations
• 3+ years reviewing medical claims
• Knowledge of provider reimbursement methodologies

Nice To Haves

• QNXT claims experience
• Claims editing
• Knowledge of healthcare billing standards and code sets

Responsibilities

• Collect, analyze, and interpret operational data to identify trends, patterns, and insights that inform decision-making and drive improvements in operations.
• Analyze operational issues, incidents, and provider complaints and identify root causes, propose solutions, and collaborate with relevant teams to implement corrective actions, claims payment reconfiguration and prevent recurrence.
• Apply knowledge of medical coding and billing to ensure accurate and efficient claims processing.
• Review and analyze complex claim documentation, assess policy coverage and claim validity, collaborate with internal and external stakeholders, and contribute to process improvement initiatives.
• Identify potential risks and issues that could impact health plan operations success and develop mitigation plans to address them proactively.
• Ensure that program deliverables meet quality standards and comply with relevant healthcare regulations and best practices.
• Implement change management strategies to address resistance and ensure smooth transitions during program implementation.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager