CVS Health

Manager, Clinical Adjudication – Prior Authorization Solutions

CVS Health

full-time

Posted on:

Location Type: Remote

Location: Arizona • Illinois • United States

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Salary

💰 $60,300 - $145,860 per year

About the role

  • Lead and close deliverables related to department initiatives and PA activities in a timely manner
  • Support CAPAS service catalog offerings
  • Maintain CAPAS service-related job aids and documentation
  • Drive innovative improvements across CAPAS operations
  • Validate functionality of new programs and innovations
  • Support implementation of client PA files during the clinical review portion of member data transitions
  • Assist partners in understanding adjudication claim processing
  • Provide training and cross-training to internal CAPAS team members, including new hires and advanced deep-dive sessions

Requirements

  • Minimum 5 years of experience with RxClaim, specifically in adjudication related to Prior Authorization overrides
  • Experience running queries in RxClaim and/or Data Warehouses
  • Advanced proficiency in Microsoft Office Suite, particularly Excel, Access, and Visio
  • Knowledge of CVS Caremark clinical programs (e.g., Benefit plan setup, formularies, utilization management) (Preferred)
  • Experience developing or enhancing training materials (Preferred)
  • Familiarity with Microsoft Power Platform (Preferred)
  • Bachelor’s degree required; equivalent work experience may substitute
Benefits
  • Affordable medical plan options
  • 401(k) plan (including matching company contributions)
  • Employee stock purchase plan
  • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
  • Paid time off
  • Flexible work schedules
  • Family leave
  • Dependent care resources
  • Colleague assistance programs
  • Tuition assistance
  • Retiree medical access
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
adjudicationPrior AuthorizationRxClaimdata queriestraining material developmentMicrosoft ExcelMicrosoft AccessMicrosoft VisioMicrosoft Power Platformclinical program knowledge
Soft Skills
leadershipcommunicationorganizationaltraininginnovationcollaborationproblem-solvingcross-trainingsupportdocumentation