CVS Health

Operations

• Independently leading dozens of partners across Clinical Operations, Medical Affairs, Legal, Sales, Account Management, Data Science & Engineering, IT, Client Analytics to structure and execute on new program designs and enhancements
• Partner with Marketing, Sales, and Account Management to communicate program performance and our product roadmap
• Build business cases to justify and prioritize product enhancements and design a measurement strategy to measure their impact
• Define longitudinal patient journeys that meet engagement and clinical outcomes, write requirements, and then partner with Operations and Technical stakeholders to bring these experiences to life
• Design, enhance, and manage patient and clinician experiences, processes, protocols, assessments, and workflows
• Develop and maintain strong, strategic relationships with key suppliers and matrix partners to drive partnership and performance
• Evaluate KPI and SLA performance, measuring program efficacy to formulate and subsequently deliver upon quality improvement plans
• Leveraging data-driven insights and a deep understanding of patient and client needs and market dynamics to identify and prioritize items enhancement
• Conducting deep dive quantitative and qualitative analyses to identify opportunities for innovation and process improvement

Senior Manager, Product Strategy and Operations

Manager

• Designs client-specific and/or cross-functional solutions to address challenges related to Star Ratings performance
• Oversees development of the organization's client-specific government programs action plan to ensure compliance with the Star Ratings program
• Assesses the development of Star ratings opportunities, develops strategies, presents recommendations, and implements solutions to improve overall performance
• Confers with regional and local account management and sales teams on Star ratings strategies based on clinical intervention services
• Assists with support in the resolution of complex Star ratings issues and requests, as well as assessment of program needs to expand existing opportunities
• Supports initiatives in collaboration with senior management, stakeholders, and senior individual contributors
• Attends ongoing professional development courses staying up-to-date with industry regulations and best practices
• Evaluates performance through regular, timely feedback to ensure delivery of exceptional services and engagement, motivation, and team development

Manager, Stars Navigator

Analyst

• Participate in complex medical economic projects (e.g. Medical Cost Savings Initiatives)
• Project oversight including initiation, identification and completion of key deliverables
• Development of provider fee schedules
• Implementation of key medical economics business efforts
• Accountable for all financial projections associated with projects

Senior Analyst, Medical Economics

Collections

• Third party follow-up associated with the dispensing of prescription medication via telephone, Internet, and in writing.
• Follow-up on unpaid, recouped payments, and underpaid claims.
• Resolve issues with nonpayment of invoices due to insurance problems that may have resulted from incorrect or incomplete information, therapy changes, and pharmacy or shipping errors.
• Maintain supporting chronological notes that detail action taken to resolve outstanding account balances.
• Maintain patient demographic information and data collection systems.
• Research and respond by telephone, via the internet, and in writing to insurance companies and governmental payers regarding collection issues and problems.
• Contact patients and Physician’s offices as well as insurance companies as needed in order to expedite claims processing.

Medical Insurance Collections Coordinator

Accounts Receivable

• Assist the Accounts Receivable Manager, leading the team to ensure accurate and timely recording of financial transactions
• Support development of the team, ensuring accounting processes are compliant with accounting principles and regulations
• Act as a point of escalation and assist the team with research and problem solving
• Monitor receipt and invoice processes to ensure completion, adhering to accounting principles and company guidelines
• Post receipt and invoice batches as needed
• Oversee GAAP and SOX audit deliverables for accurate and timely completion
• Train and develop staff to ensure that each team member has appropriate workload
• Work with Accounts Receivable Manager preparing metric reporting and ensuring metrics are properly met
• Monitor process policy & procedures for accuracy and timeliness on a regular basis
• Assist with review of AR aging and actioning outstanding issues
• Act as point of escalation, coordinate with other leaders and teams, and complete projects distributed by leadership as needed
• Perform other duties as assigned

Accounts Receivable Team Lead

Solutions Engineer

• Accountable for the business solution designs for key strategic initiatives
• Act as the chief SME architect for a key strategic initiative
• Look around the corner at emerging technologies and advise senior leadership
• Play a key role in furthering the modernization journey for PSS IT
• Provide leadership and oversight to solution engineers and architects
• In depth experience in performing Buy vs Build analysis
• Lead and participate in architecture design reviews
• Develop reference architecture and implementation
• Identify PBM apps targeted for refactor and optimization
• Lead and drive proofs-of-concept and technology deep-dives
• Advise App development teams with technical roadblocks
• Recommend or assess opportunities to drive cost efficiencies aimed at simplicity, configurability and eventual elimination of technical debt

Principal Solution Architect – Finance

Data Scientist

• Extract key information from legal contracts using AI
• Develop and optimize extraction algorithms
• Build and track system KPIs
• Quantify business results from system improvements
• Design data solutions that meet client requirements
• Apply data science and ML knowledge to improve contract extraction capabilities
• Develop analytical frameworks and performance dashboards
• Communicate with stakeholders to understand needs and provide solutions
• Stay current on innovative data analysis techniques

Data Scientist – Commitments AI

Financial Planning and Analysis

• Analyzes Commercial and Medicare formularies to determine client eligibility for manufacturer rebate contracts
• Gathers documentation, reviews contract language and provides feedback
• Evaluates new and varied situations dealing with plan design, formulary listing, contract interpretation, and trade negotiation
• Conducts ad hoc research to support forecasting and underwriting processes
• Investigates manufacturer disputes, supporting client and manufacturer audits
• Collaborates with colleagues and management to resolve issues and improve processes
• Adheres to quality control procedures to ensure timely and accurate research results are published monthly for all formularies and drugs

Senior Analyst, Financial Operations – Rebate Research

Consultant

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Utilization Management Nurse Consultant – Medical Review

• Work intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients
• Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues
• Consult with supervisor and others in overcoming barriers in meeting goals and objectives
• Present cases at case conferences for multidisciplinary focus to benefit overall claim management
• Use a holistic approach, consulting with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives
• Utilize case management processes in compliance with regulatory and company policies and procedures
• Utilize motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs
• Identify and escalate member’s needs appropriately following set guidelines and protocols
• Actively reach out to members to collaborate/guide their care
• Perform medical necessity reviews

Case Manager, Registered Nurse – Oncology Experience Required

• Oversees the day-to-day management and leadership of the plan document drafting team approximately 13 employees.
• Develops and coaches the team to effectively manage client expectations and business needs related to plan drafting and issue resolution.
• Designs and implements processes to ensure efficient, accurate drafting, with a strong focus on delivering a consistently high-quality client experience within the department while maintaining regulatory compliance.
• Directs support operations for plan sponsors, ensuring timely and effective resolution of inquiries, issues, and requests.
• Develops processes and procedures to streamline plan sponsor support activities, optimizing efficiency and quality of service delivery.
• Assists with the development of a team of support professionals, providing coaching, training, and performance feedback to ensure high levels of customer satisfaction and operational excellence.
• Analyzes customer feedback and metrics to identify trends, patterns, and areas for improvement in plan sponsor support, implementing initiatives to enhance customer experience and satisfaction.
• Serves as a primary point of contact for plan sponsors, addressing complex inquiries, resolving escalated issues, and building strong relationships to enhance customer loyalty.
• Collaborates with cross-functional teams, such as sales, account management, and product development, to gather and share customer insights, driving improvements in products, services, and processes.
• Ensures compliance with regulatory requirements, industry standards, and contractual obligations in all plan sponsor support activities, maintaining adherence to relevant guidelines and protocols.
• Administers regular performance evaluations and audits to assess the effectiveness and efficiency of plan sponsor support operations, making data-driven recommendations for enhancements and process optimization.
• Stays informed about industry trends, market developments, and best practices in plan sponsor support, continuously expanding knowledge and leveraging insights to deliver exceptional support services.

Manager, Operations Plan Document Services – Self-Funded Plans

• Create, review, and audit medical determination letters including approvals, extensions, and denials
• Ensure all documentation meets regulatory, accreditation, and internal quality standards
• Support effective medical management by facilitating clear communication across internal teams and external partners
• Maintain accurate, complete records for compliance and risk‑management requirements
• Contribute to overall quality and effectiveness of healthcare services through attention to detail and process consistency

Utilization Management Nurse Consultant – Medicaid Program

Sales

• Develops and implements sales strategies to sell products and services to new large group accounts or government programs in an assigned business segment, product, or geography.
• Performs business development activities in pursuit of new growth channels and identifies potential new clients in a specified territory or geographic area.
• High influence on sales and retention business.
• Develops new business opportunities and cultivates strong relationships to generate new sales of large or complex accounts and prospects.
• Implements strategies necessary to attain sales objectives in assigned areas.
• Manages complex negotiations and consults on challenging renewals.
• Works with clients to identify their needs and utilize Aetna's full product array to create comprehensive packages.
• Coordinates sales materials and oversees communication among stakeholders to deliver successful presentations.
• Identifies and capitalizes on market trends and collaborates with internal teams for profitable growth.

Dental, Vision, Voluntary Sales Director

Actuary

• Drive Aetna’s point of view on Machine Readable Files
• Manage a team of 3
• Evaluate Aetna’s self-insured trend performance
• Manage out of network savings analyses
• Build relationships with Health Benefit Consultants
• Collaborate with internal business partners to improve usability
• Educate consultants on data and influence their use

Lead Director, Actuarial – Self Insured

Support Engineer

• Work through timely technical responses to inquiries from CVS store employees, pharmacy, and Minute Clinic employees
• Document problems, complete problem tickets, and request information in support tools
• Maintain knowledge with accurate up-to-date information relating to current policies, procedures, and troubleshooting techniques
• Effectively manage call workload
• Provide outstanding customer support by analyzing, diagnosing, and resolving problems within service level agreements
• Collaborate well in a team environment