Senior Manager – Medical and Payment Policy Performance Research, Correct Coding Analysis

CVS Health

Senior Manager managing policy and coding reviews for CVS Health. Evaluating clinical and payment policies to ensure compliance and optimize performance.

Posted 4/22/2026full-timeRemote • Florida • 🇺🇸 United StatesSenior💰 $67,900 - $182,549 per yearWebsite

Tech Stack

Tools & technologies

PMP

About the role

Key responsibilities & impact

Independently develops and manages assigned policy and coding reviews by evaluating clinical and payment policies and identifying potential issues.
Ensures coding aligns with defined medical and pre-payment policies, identifies opportunities to optimize performance, and supports organizational goals and regulatory requirements.
Partners closely with claims operations to apply policy intent across end-to-end claims processing (intake, edits, adjudication, denials, appeals, and adjustments) and to drive consistent, compliant outcomes.
Collaborates with cross-functional teams—such as IT, compliance, operations, and provider relations—to ensure seamless integration of claims coding changes and resolve complex configuration issues.
Monitors and reports on claims coding and configuration accuracy, trends, and key performance indicators (KPIs), providing actionable insights for process improvement.
Leverages claims processing experience to evaluate end-to-end workflows (front-end edits, adjudication logic, denials, appeals, and adjustments) and translate findings into actionable policy/coding guidance and claims platform configuration or testing support.
Stays up to date with industry developments, payer and provider requirements, and regulatory changes affecting claims coding and configuration.
Develops and maintains documentation for identifying claims trends, pinpointing policy or coding issues, and communicating required configuration changes across claims platforms.
Leads or participates in audits and reviews related to claims coding and configuration, ensuring readiness and timely resolution of findings.
Provides expert guidance on correct coding practices, resolving complex coding issues and supporting audits as needed.

Requirements

What you’ll need

5+ years of experience in healthcare claims administration, coding, or configuration
Proven expertise in configuration testing, defect management, and process optimization specifically for medical and pre-payment policy.
Strong analytical, organizational, and problem-solving skills.
Excellent communication and interpersonal abilities, with experience collaborating across technical and non-technical teams.
Proficiency with claims adjudication platforms, testing tools, and data analysis applications.
Project management certification (e.g., PMP, Lean Six Sigma) preferred
Experience with system migrations, medical and pre-payment configuration changes, or healthcare technology implementations.
3-5 years claims processing systems, including HRP, ACAS and QNXT coding methodologies (ICD, CPT, HCPCS), and regulatory requirements (e.g., CMS, HIPAA).

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources, based on eligibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

healthcare claims administrationcodingconfiguration testingdefect managementprocess optimizationclaims processing systemsICD codingCPT codingHCPCS codingregulatory requirements

Soft Skills

analytical skillsorganizational skillsproblem-solving skillscommunication abilitiesinterpersonal abilities

Certifications

PMPLean Six Sigma