CVS Health

Claims Specialist

• Review pharmacy claims submitted through the CVS Health claims processing systems
• Identify and rectify claim inaccuracies that would result in client over-payment
• Contact pharmacies for proper documentation to ensure a claim was submitted correctly
• Monitor assigned clients and report status on a regular basis
• Follow the appropriate policies in the event of an inaccurate claim submission

Pharmacy Technician – Claims Analyst

Manager

• 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

Manager, Clinical Adjudication – Prior Authorization Solutions

Designer

• Independently leading dozens of partners across Product, Operations, Medical Affairs, Legal, Sales, Account Management, Data Science & Engineering, IT, Client Analytics to structure and execute on new product designs and enhancements
• Partner with Marketing, Sales, and Account Management to commercialize our products and communicate product 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
• Evaluate KPI and SLA performance, measuring product efficacy to formulate and subsequently deliver upon quality improvement plans
• Leverage data-driven insights and a deep understanding of patient and client needs and market dynamics to identify and prioritize enhancements
• Conducting deep dive quantitative and qualitative analyses to identify opportunities for innovation and process improvement

Senior Manager, Product Strategy and Design

Full-stack Engineer

• Communicate with business leaders to help translate requirements into functional specification
• Develop broad understanding of business logic and functionality of current systems
• Analyze and manipulate data by writing and running SQL queries
• Analyze logs to identify and prevent potential issues from occurring
• Deliver clean and functional code in accordance with business requirements and adhering to established SDLC best practices
• Consume data from any source, such as flat files, streaming systems, or RESTful APIs
• Interface with Electronic Health Records
• Engineer scalable, reliable, and performant systems to manage data
• Participate in code reviews, contributing constructive feedback to peers and integrating feedback into your own work
• Collaborate closely with other Engineers and Product Manager in your team as well as across the organization

Software Development Engineer

Actuary

• Design and conduct analyses to validate, refine, and develop key business assumptions
• Define and standardize methodologies, while establishing process for ongoing review and refresh cycles
• Gain a comprehensive understanding of business processes and systems
• Work with business teams on appropriate execution strategies for implementing assumptions
• Communicate analysis findings and recommendations to managers, supervisors, and individual contributors
• Review and interpret data models, making recommendations for planning, forecasting, and reporting
• Anticipate and recognize issues that materially affect financial results, making recommendations on these matters
• Provide support for broader actuarial priorities, such as ad-hoc analyses and strategic projects

Manager, Actuarial

Director

• Lead a national contracting team in enterprise-wide negotiations with large national provider, ensuring alignment with CVS Health’s strategic priorities.
• Manage the provider relationship, ensuring consistent execution of strategic initiatives, performance metrics, and relationship management.
• Develop and implement innovative national contracting strategies that leverage CVS Health’s integrated assets, including the care delivery model.
• Achieve strategic national network goals by successfully closing provider negotiations, managing day-to-day operations, and overseeing the full contracting lifecycle from strategy through execution.
• Drive execution and closure of complex national provider agreements, ensuring alignment with enterprise cost, adequacy, and compliance standards.
• Demonstrate strong executive presence in high-level engagements, facilitating strategic discussions with senior leadership to ensure alignment and support.
• Deliver compelling executive-level presentations that influence decision-making and advance enterprise-wide initiatives.
• Provide strategic direction and coaching to account executives to ensure high-impact engagement with Tenet and internal stakeholders.
• Manage the operational performance and infrastructure of the Tenet network to meet cost containment, profitability, and regulatory goals.
• Collaborate with Clinical and Medical Economics teams to analyze market trends and implement cost management strategies that improve medical cost outcomes.
• Evaluate market dynamics and partner with Clinical Functions to drive national initiatives that improve cost structure and partnership effectiveness.
• Oversee national agreements, Joint Operating Committees (JOCs), and complex projects, streamlining and centralizing operational processes for efficiency and scalability.
• Represent the organization in high-stakes negotiations and external engagements, ensuring alignment with legal, regulatory, and reputational standards.
• Establish national network strategy and drive innovation across traditional and emerging care models for all lines of business.
• Lead expansion efforts and strategic partnerships with Tenet to support enterprise growth and market differentiation, aligned with local and national goals.
• Foster strong collaboration across local networks and enterprise functions to ensure internal alignment and successful external partnerships.
• Develop and deliver key messaging and represent the company at industry conferences, external forums, and provider negotiations.
• Build and maintain trusted relationships with Market Chief Network Officers and Territory Chief Network Officers, and engage with Market Presidents, CFOs, and Medicare GMs to align and execute strategies that drive profitable membership growth.

Executive Director – National Network Management

Scrum Master

• Support Sr. Project Managers (or drive independently) planning, estimating, forecasting, providing oversight and day-to-day management across the full project lifecycle on small to medium size IT initiatives and projects
• Manage competing priorities
• Oversee IT budgeting and capital purchase processes
• Coordinate vendor management, both local and offshore

Senior Analyst, Scrum Master

Consultant

• Conduct telephonic outreach to members with diabetes to assess needs and close gaps in care
• Provide education and support to promote member engagement and self-management
• Identify and address social determinants of health impacting care
• Refer members to appropriate care management programs and community resources
• Collaborate with providers and interdisciplinary teams to coordinate care
• Apply nursing processes in compliance with company and regulatory standards
• Document interactions and care plans accurately in electronic medical records
• Consult with supervisors to resolve challenges and improve member outcomes

Health Coach Consultant – CDCES Certified Registered Nurse

Account Executive

• Managing sales growth by building a book of business leveraging field sales marketing activity and telesales programs
• Selling, cross-selling, up-selling, and retaining through the use of the Aetna IVL Medicare product portfolio
• Deploying an operating model that supports 3 days in the field and 2 days in a call center queue
• Owning the member relationship throughout the year as the primary contact for member inquiries
• Documenting call interactions, COIs, and lead management protocols with new and existing members
• Developing, continuously training, and learning new sales skills to support best-in-class customer acquisition metrics, sales goals, and other KPIs
• Accountable for telesales/field sales achievement of quality, sales effectiveness, retention, secret shopper initiatives, and state, federal, and CMS requirements for Medicare sales agents and programs

Field Sales Representative

Frontend Engineer

• Accurately and efficiently reading, interpreting, and entering prescriptions into our system.
• Ensure patients receive their correct prescriptions in a timely manner, directing questionable prescriptions to the prescriber for clarification, and entering complete prescription information once clarification is received.
• Meet specified production and quality standards as defined by the management team.
• Offer solutions needed to help enter patient and prescription information into our system, and faxing physicians for prescription clarification, substitutions, and formulary changes.
• Perform other pharmacy functions as required to support development and maximize workflow.
• Work in a complex, team-oriented environment while developing and strengthening technical skills and pharmacology knowledge.

Pharmacy Technician II, Front End

Engineering Manager

• Engineer highly scalable, distributed web services & applications
• Work on enterprise services and applications
• Be responsible for the security and privacy of all protected health information that may be accessed during everyday work activities
• Deliver high-quality code to production
• Suggest paradigms, toolsets, frameworks, or third party solutions and work to establish consistency in terms of process and approach.
• Support team members and drive: Partnership with and execution of product direction across the group.
• Adoption of new technology and best practices.
• Fostering a security mindset, helping to train and implement code security best practices within the team.
• Aggregating and reviewing engineering performance and application uptime KPIs.
• Strong mentorship and coaching to junior software engineers leading software design and implementation of most projects.
• Identifying opportunities for improvement across dependent services and teams.

Senior Software Engineering Manager

Compliance

• Lead and implement an effective Compliance Program as described in CMS Medicare Managed Care Manuals/regulations
• Develop and manage compliance strategies, programs, and processes
• Track, analyze, research, interpret and monitor applicable CMS
• Maintain in-depth working knowledge and expertise in Medicare regulations
• Build and maintain positive relationships at senior levels
• Monitor and audit as outlined in Medicare Compliance Work Plan
• Lead and support broader compliance initiatives and needs as assigned

Manager, Medicare Compliance

• Manage and lead a group of colleagues responsible for pulling together responses to member and provider regulatory complaints
• Oversee the scheduling, drafting, timeliness and quality of regulatory responses
• Proactively monitor team case load, status of response letters and associated due dates
• Interface and negotiate with state and federal regulators, as needed
• Build, maintain and promote positive and effective working relationships with internal and external stakeholders
• Identify opportunities to streamline processes and improve efficiencies within the RRT and key business partners
• Encourage staff to embrace new processes and identify change management opportunities within the team
• Hold team accountable for meeting goals, due dates and expectations, identifying areas of individual performance concerns and coaching opportunities

Senior Manager, Regulatory Resolution

• Manage sales growth by building a book of business leveraging field sales marketing activity and telesales programs
• Sell, cross-sell, up-sell, and retain through the use of the Aetna IVL Medicare product portfolio
• Support organization by reducing acquisition costs and increasing field agent productivity
• Own member relationship and serve as the primary contact for member inquiries
• Document call interactions and manage lead protocols

• Partner with teams to find opportunities for process improvement and automation
• Research and implement technical solutions (AI tools, internal apps, ETL, custom code, etc.)
• Gather, analyze, and interpret data from many different sources
• Present findings clearly to internal and external partners
• Create documentation for all technical solutions
• Build and maintain dashboards and reports that support performance and continuous improvement

Pharmacy Technician – Claims Analyst

Manager, Clinical Adjudication – Prior Authorization Solutions

Senior Manager, Product Strategy and Design

Software Development Engineer

Manager, Actuarial

Executive Director – National Network Management

Senior Analyst, Scrum Master

Health Coach Consultant – CDCES Certified Registered Nurse

Field Sales Representative

Pharmacy Technician II, Front End

Senior Software Engineering Manager

Manager, Medicare Compliance

Senior Manager, Regulatory Resolution

Field Sales Representative

Senior Analyst, Corporate Compliance