CVS Health

Risk

• Function as a face of Revenue Integrity across internal market teams
• Develop and deliver executive level presentations highlighting key performance drivers, challenges, and solutions
• Investigates operational issues that impact market performance – work with business partners to implement solutions
• Track deliverables and identify barriers in market engagement in conjunction with implementing resolutions
• Assist with development of educational material to support market intelligence
• Engage with market clinical team, care management team, member services team; attend market level meetings as appropriate
• Apply project management skills to coordinate deliverables, track timelines, and manage competing priorities
• Work closely with the Informatics team to review requirements, dashboards, reports including any enhancements
• Utilize data analyses using national tools in conjunction with the corporate lead to identify areas of opportunity
• Produce and present market specific performance specific to Medicaid Revenue Integrity efforts at various governance, market, and executive leadership meetings
• Monitors program or programs that are jointly accountable for risk adjustment strategy, performance, and results within a designated market(s)
• Responsible for identifying and recommending nuanced market risk adjustment strategies and collaboratively executing tactics to focus, maximize and achieve market success, including market referrals
• Coordinate with local markets to drive correctness, completeness, accuracy, and timeliness of risk score performance
• Collaborate on market specific strategies that drive member engagement in risk adjustment programs
• Stay abreast of regulatory changes and leading risk adjustment practices and tools to maximize the effectiveness and efficiency of the team
• Partner with segment product, sales, network, clinical teams to implement processes aimed at strengthening member and provider engagement of Revenue Integrity programs resulting in improved outcomes

Medicaid Risk Adjustment Market Manager

Analyst

• Develops and implements analytic solutions to address specific business problems or challenges.
• Designs and executes analytical models, algorithms, and experiments to generate insights and recommendations.
• Prepares and presents reports, dashboards, and visualizations to communicate findings to stakeholders.
• Communicates technical concepts and analytical results to non-technical audiences in a concise and understandable manner.
• Collaborates with clients or internal stakeholders to understand their business needs, objectives, and analytical requirements.
• Conducts meetings, interviews, and workshops to gather data requirements and define the scope of analytic projects.
• Performs data validation, conducts robustness checks, and implements quality control measures to ensure the validity of the analysis.
• Reviews and validates the work of other analysts to maintain high standards of analytical excellence.
• Collects and analyzes data from various sources, such as internal databases, market research, customer surveys, and external data providers.
• Explores innovative approaches and tools to improve analytic capabilities and enhance business outcomes.
• Identifies opportunities for process improvement, automation, and efficiency gains within the analytic services function.
• Conducts scenario analyses, predictive modeling, and other analytical techniques to evaluate potential business outcomes and assess risks.
• Applies advanced analytical methods to extract meaningful insights that support business objectives.
• Uses statistical analysis techniques, data mining, and predictive modeling to uncover patterns, trends, and correlations within the data.
• Provides guidance and support to junior analysts, promoting knowledge sharing and skill development within the team.
• Works closely with data engineers, IT professionals, and other analysts to acquire, transform, and integrate data from multiple sources.

Senior Analyst, Analytic Services

Systems Engineer

• Define and execute the long-term engineering strategy for IBM zSystems, encompassing platform modernization, automation frameworks, and the adoption of AIOps and AI-enabled operations capabilities
• Build, develop, and retain a high-performing organization of platform engineers, systems administrators, and operations specialists, fostering a culture of innovation, accountability, and continuous improvement
• Own enterprise platform reliability, operational resilience, and system availability for mission-critical transaction processing, including SLA governance and incident management
• Lead security-by-design principles, compliance engineering, and vulnerability remediation across all mainframe platforms and tooling
• Champion integration initiatives connecting mainframe systems with cloud platforms, APIs, and modern application architectures to support broader enterprise modernization goals
• Manage strategic vendor relationships, including IBM and automation platform providers, and exercise stewardship over technology budgets and investment priorities
• Drive cross-functional collaboration with architecture, security, application, and business teams to ensure the platform supports and accelerates enterprise objectives
• Serve as an executive-level advocate for the mainframe platform, translating complex engineering strategy into business value narratives for senior leadership and board-level audiences when required

Lead Director – Mainframe Systems Engineering

Operations

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
• Analyzes reports for assignments/trends/metrics/issues
• First in line for questions from frontline staff on cases
• May be required to proctor RN/MD rounds
• Assists with escalated case reviews/facility issues
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
• Communicates with providers and other parties to facilitate care/treatment
• Identifies members for referral opportunities to integrate with other products, services and/or programs
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Med Ops Utilization Management Team Lead – Medicare

Manager

• Lead, coach, and develop a team of analysts supporting production support cost centers and clinical programs cost centers; set priorities, clarify ownership, and ensure timely, high-quality deliverables.
• Own the planning cadence for supported cost centers, including annual budget development and periodic reforecasts; establish assumptions, document methodologies, and coordinate inputs with Finance and Operations partners.
• Monitor actual spend and operational drivers; identify risks, trends, and opportunities, and recommend corrective actions to maintain alignment with financial targets.
• Translate complex financial and operational data into clear narratives, executive-ready materials, and recommendations for leaders and stakeholders.
• Drive standardization and continuous improvement of forecasting models, templates, and reporting processes to improve accuracy, transparency, and efficiency.
• Serve as Strategic Planning lead for Power BI dashboard development: define requirements, partner with data owners, design measures and visuals, validate outputs, and manage iteration based on stakeholder feedback.
• Establish and maintain data governance for reporting (definitions, refresh cadence, controls, and documentation) to ensure consistent and trusted insights across Strategic Planning.
• Partner cross-functionally with other Strategic Planning teams to align metrics, assumptions, and reporting standards; support ad hoc analyses and strategic initiatives as needed.

Manager, Strategic and Resource Planning

Medical Reviewer

• Prior authorization review of physical and behavioral health related services
• Utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program
• Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs
• Taking provider calls related to prior authorization questions and making calls to members to inform of the coverage determination
• Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care
• Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members
• Identification of members who may benefit from care management programs and facilitation of the referral
• Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization
• Sedentary work involving periods of sitting, talking, and listening
• Performing other duties as assigned.

Prior Authorization Clinical Reviewer

Account Manager

• Examines sales, account management, and business retention metrics for products and services
• Manages a portfolio of client accounts ensuring high levels of customer satisfaction
• Analyzes complex client data, account performance, and market trends
• Develops complex account plans and strategies to maximize revenue generation
• Conducts routine business reviews with clients discussing performance metrics
• Collaborates with internal stakeholders such as sales, marketing, and product teams
• Implements proactive account management and customer support
• Identifies and assesses risks within client accounts with mitigation strategies

Account Manager, East Region

• Recruits providers as needed to ensure network adequacy and achievement of network expansion goals
• Negotiates contracts with health care providers using pre-determined internal guidelines and financial standards
• Develops rate proposals and performs financial analyses to ensure that results are within pre-determined targets
• Manages contract performance and works with various internal departments to address questions, issues, and activities related to execution, loading, and ongoing maintenance of provider contracts
• Negotiates settlements as needed

Contract Negotiation Manager – Florida

Support Engineer

• Analyze and document business data and processes
• Conduct root cause analysis
• Create reports or other solutions as needed to support business needs
• Conduct analysis or produce reports of varied claim and encounter data
• Write simple to complex SQL queries, procedures, and reports
• Proactively define, identify, develop, and implement system enhancements
• Assists in the development and prioritization of system updates
• Executes test scripts and reports outcomes or defects
• Establish relationships with internal and external stakeholders

Senior Analyst, Informatics – Encounter Technical Analyst

Financial Planning and Analysis

• Lead and develop a team preparing periodic financial statements
• Ensure financial reports comply with regulations, standards, and company policies
• Review and audit consolidation journal entries
• Eliminate intercompany transactions
• Consolidate divisional and subsidiary financial results accurately and on time

Lead Director, Financial Reporting, Analysis

Sales

• responsible for driving year over year growth across all products with specific focus on new, large group government and multi-employer labor entities
• partners with sales resources on strategic account development and strategy execution
• represents the needs of the aligned territory to senior leadership and shared services
• performs business development activities in pursuit of new growth channels
• identifies and capitalizes on external emerging trends in the marketplace
• cultivates strong external relationships including employers, consulting firms, professional organizations, etc.
• mentors and supports service team, peers, and sales team

Vice President, Sales & Client Management – Public & Labor

Architect

• Design analytical models that represent how core business processes operate across Oak Street Health.
• Translate complex operational systems into structured, reusable analytical frameworks that support measurement, forecasting, and decision making.
• Build and maintain Power BI semantic models that expose consistent metrics and business definitions across the organization.
• Investigate operational data sources to understand how the business actually functions and identify opportunities to improve measurement and transparency.
• Partner with data engineering, analytics engineering, product, and operational teams to inform upstream data requirements needed to support robust analytical models.
• Contribute to the development of analytics-ready datasets and semantic models that can support advanced analytics, machine learning, and AI-driven decision support.
• Develop analytical artifacts including models, metric frameworks, and reports that help the organization monitor performance and identify opportunities for improvement.

Principal Analytics Architect – Decision Science

Data Scientist

• Utilize advanced mathematical and statistical methods to solve business problems under the supervision of senior data scientists
• Execute exploratory data analysis to validate and quantify trends identified by partner organizations.
• Develop insights, visualizations, and other data artifacts that support broader data science initiatives
• Wrangle and analyze large structured and unstructured datasets in a highly repeatable fashion
• Demonstrate strong communication skills (both written and verbal) and a positive, solution-oriented attitude

Data Scientist, Decision Sciences Team

Chief Marketing Officer

• Serve as a strategic and operational partner to the Health Plan CEO, COO, CFO and other executive team members in Medicaid driving clinical excellence.
• Accountable for overall plan results and the delivery of high-quality cost-effective products and services.
• Develop, implement, support, and promote population health strategies.
• Serve as clinical executive leader for State regulators, providers, and other key partners.
• Ensure clinical programs are compliant with all national and state regulations.

• service strategy to ensure renewal and growth of business and retention of members for assigned accounts
• achieves individual growth/retention targets and customer satisfaction levels
• creates collaborative partnerships with sales to develop a comprehensive growth strategy for assigned book of business
• executes tactical components of the account teams business plan for each customer
• demonstrates proactive ability to diagnose and fix root cause drivers of service problems
• develops and manages service plans in the most proactive and strategic manner possible
• proactively identifies potential service issues and takes steps to resolve those service issues