CVS Health

Software Engineer

• supports daily ITGS operations focused on Medicare Part D enrollment processing
• analyzes, runs, monitors, and maintains daily batch operations, FTP, and ETL processes
• troubleshoots job failures, researches business and IT requests, creates and schedules jobs, supports production activities, and assists with release deployments
• handles requests from internal and external customers, clients, and vendors while meeting service-level expectations
• partners with business, development, and infrastructure teams to deliver projects, system upgrades, and maintenance requests on time and with high quality

Senior Analyst, Application Developer

Medical Director

• Provide clinical leadership and expertise to Medical Management staff, ensuring timely, consistent, and evidence-based responses to members and providers.
• Lead utilization management and quality assurance activities, including oversight of medical necessity reviews and case management initiatives.
• Support medical management programs through active participation in interdisciplinary clinical team activities and strategic decision-making.
• Serve as the primary clinical and business liaison to network providers and healthcare facilities, fostering collaboration and supporting the effective implementation of medical services programs.
• Conduct predetermination reviews and claim determination reviews, applying clinical judgment and expertise in medical coding, reimbursement, and coverage policies.
• Provide guidance and consultation on complex clinical cases, helping ensure quality outcomes and regulatory compliance.
• Support the development and continuous improvement of medical management strategies, policies, and processes.

Medical Director – Pain Management

Consultant

• Support the communications team in ensuring optimal understanding of benefits programs.
• Provide updates on any changes in benefits or programs that will impact employee experience and communications materials.
• Provide strategic counsel and develop a long-lasting “trusted advisor” relationship with account management team and client stakeholders.
• Proactively meet with the client not only on projects, but also to stay connected to the business needs and ensure an excellent working relationship.
• Assist in the creation of creative brief and content outlines for communications projects.
• In partnership with copy team, own and be accountable for the accuracy, consistency, and compliance of all benefits-related communications across deliverables.
• Partner with copywriters and designers to provide benefits education and review communications materials during and after creative development for quality, consistency, accuracy and clarity.
• Own key internal knowledge base (benefit plan descriptions, content libraries, etc.) and work with copy team to ensure consistency and accuracy across all materials.
• Engage with third-party benefits vendors and administrators to interpret plan changes and help translate them into clear, actionable communications strategies.
• Help synthesize data analytics and reporting to inform opportunities to improve employee experience and understanding of benefits.
• Make recommendations to the communications and account teams.
• Assist in the organization of an annual strategy meeting with the client.

Benefits Consultant

Account Executive

• develops and implements sales strategies to sell Supplemental Health products and services to new large group accounts and public entity customers
• performs business development activities in pursuit of new growth channels
• identifies potential new clients in a specified territory or geographic area
• drives new business revenues through the sale of new customers or new products to existing customers
• collaborates with internal business partners to identify targeted opportunities
• manages the integration of client's and Aetna’s internal organizations and partners cross-functionally
• ensures product, pricing and services meet client's needs while meeting Aetna revenue growth and profit objectives
• accountable for overall Sales Planning, Distribution Channel, Sales Processes, RFP & Quoting Process.

Supplemental Health Sales Executive

• develops and implements sales strategies to sell Supplemental Health products and services to new large group accounts and public entity customers
• performs business development activities in pursuit of new growth channels and identifies potential new clients
• cultivates strong, productive, and influential relationships to generate new sales including large accounts and prospects
• implements strategies necessary to attain sales objectives in assigned territory
• collaborates with internal business partners to identify targeted opportunities
• identifies opportunities to partner with the client

Technical Project Manager

• Drive strategy alignment, planning, and execution rhythm across teams.
• Monitor dependencies and cross-functional efforts to mitigate critical risks to drive successful execution.
• Align portfolio objectives with organizational goals, ensuring that all projects contribute to the overall strategy.
• Support critical projects and initiatives, ensuring alignment with strategic goals and timely execution.
• Track progress and report on key performance indicators.
• Managing and tracking utilization and forecasted investments against the annual plan, ensuring financial resources are allocated efficiently.
• Develop and disseminate clear and effective communication materials, including presentations, reports, and memos for both internal and external stakeholders.
• Build and maintain relationships with leaders, cross-functional teams, and other program managers to facilitate collaboration and knowledge sharing.
• Gather, analyze, and present data to support decision-making processes, identify trends, and drive continuous improvement efforts.
• Act as a key problem-solving resource helping to address complex issues and challenges within the organization.
• Establish scalable processes, systems, and workflows to improve operational efficiency within the organization.
• Organize and lead meetings, and set agendas ensuring that discussions are productive, action items documentation, and decisions are followed through.
• Flexibility to adjust strategies and priorities in response to changing market conditions and organizational needs.

Digital Product Manager / Project Manager

Compliance

• Serve as the designated Compliance Officer for Aetna’s IL Medicaid health plan
• Acts as the primary liaison to the state Medicaid agency, facilitating compliance and contract-related communications and activities.
• Facilitates the preparation for and management of external audits conducted by state Medicaid and related agencies or partners
• Lead and execute all elements of the Medicaid compliance program for Aetna’s IL Medicaid health plan.
• Conduct research and develop recommendations to help develop compliant business operations, processes and policies in accordance with state specific Medicaid program requirements.
• Develop compelling, strategic, and appropriate compliance related communications on behalf of the health plan in response to state Medicaid agency inquiries or requests.
• Maintain an in-depth working knowledge of the health plan’s contractual, regulatory, and program policy related obligations as a Medicaid managed care organization and serve as a resource to health plan and growth partner staff for education, training, and business decision making purposes.
• Ensure that current resource tools and other internal deliverables such as current contract library, regulatory reporting assignments, risk assessments, risk tracking lists, internal reporting systems and summaries, and other department wide tools are current and accessible to business partners to ensure the appropriate monitoring and oversight of health plan compliance processes.
• Utilize systems unique to job functions, including standard-issue software such as Microsoft products and compliance specific tools such as Archer; maintain system documentation, serve as subject matter expert, train users of system, contribute to system design, oversight or maintenance.
• Lead and direct oversight and monitoring activities to evaluate levels of compliance with new and existing Medicaid managed care organization requirements across the business; support business partners in the development of mitigation and corrective action plans and effectively escalate risks, concerns and other issues through appropriate channels.
• Maintain positive, productive relationships with internal and external senior level constituents to effectively communicate and influence ethical and compliant outcomes.
• Oversee the submission of required regulatory reports (standard and ad hoc), including the completion of high level quality reviews prior to submission and the maintenance of tracking systems and tools to document ownership, reporting requirements, and monitor timely delivery and acceptance of reports.
• Provide training and guidance to less experienced team members to accomplish goals.
• Other duties as assigned.

Lead Director – Corporate Compliance

Data Scientist

• own multiple concurrent projects across model development, strategic analysis, and analytics product delivery — framing the business question, designing the approach, building the solution, and presenting findings to senior stakeholders (Lead Director, Executive Director, AVP)
• set technical direction for your workstream, mentor junior data scientists, and partner directly with business leaders across sales, underwriting, and finance to turn analysis into action

Senior Data Scientist

Platform Engineer

• Design, build, and maintain key components of our data platform automation for provisioning, backups, and user management
• Troubleshoot and resolve complex performance and reliability issues in our data systems
• Proactively identify opportunities to improve data streaming services, security, scalability, and automation
• Participate in an on-call rotation to support the team's critical services
• Mentor junior engineers on the team

Senior Platform Engineer, Data & Performance Enablement

Manager

• Visiting members in their homes to evaluate for appropriateness for waiver services, writing the waiver and submitting for approval.
• Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness.
• Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits.
• Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning.
• Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members.
• Collaborates with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Case Manager, Registered Nurse - Field MI

Clinical Operations

• Working on the development, creation, maintenance, and management of the client-specific clinical benefits, formularies, and utilization management edits.
• Supporting the clinical and benefit teams in all clinical benefit and formulary set-up/coding efforts required to meet client-specific needs and requirements.
• Performing tasks associated with clinical benefit and formulary documentation and reporting needs across all lines of business offered by the client.
• Ensuring all relevant activities are at highest level of clinical appropriateness, accuracy, clinical consistency, and in full compliance with client requirements and applicable rules and regulations.

Clinical Pharmacist, Clinical Account Operations

Patient Care Coordinator

• Serve as the first point of contact for patients, caregivers, and healthcare providers—answering questions, resolving concerns, and providing education.
• Guide new patients through the onboarding process with empathy, professionalism, and attention to detail.
• Handle a high volume of phone calls, using active listening and de-escalation skills for challenging situations.
• Multitask and prioritize effectively—navigating multiple computer screens and systems while capturing all necessary patient information.
• Work independently from home, reliably following shift, break, and lunch requirements.
• Collaborate with internal teams to support referrals and admissions.

Pharmacist

• Collaborates with the technicians and prior authorization team members to process referrals
• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design
• Guarantee that decisions regarding cases are conveyed promptly and efficiently
• Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients
• Establishes and maintains communication among CVS Caremark, health plan, and employer group staff
• Maintains professional and technical knowledge of drug and disease states
• Performs other related projects and duties as assigned

Clinical Pharmacist – Prior Authorization

Data Analyst

• Design and maintain the OpEx semantic data layer in Snowflake
• Develop and deploy advanced analytical models and AI/ML applications
• Build and maintain automation flows that eliminate manual reporting
• Develop network-level PowerBI dashboards
• Own OpEx's platform requirements and represent them directly in platform design
• Drive the OpEx analytics and AI roadmap
• Use data, modeling, and AI to optimize WMS/LMS settings
• Lead cross-functional analysis with routing, transportation, and inventory teams
• Translate analytical findings into actionable recommendations
• Lead root cause analysis and corrective action efforts
• Train OpEx colleagues and site leadership on tools and methods
• Mentor OpEx colleagues on advanced analytical techniques
• Plan and execute multiple projects in parallel

Senior Manager, Operational Excellence Analytics

Investigator

• conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
• Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment
• Conduct thorough research on subject(s) and related entities
• Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection
• Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme
• Research and prepare cases for both clinical and legal review
• Collaborate with Medical Directors on clinical issues and medical record questions
• Accurately documents all case activity and communications in designated case tracking system
• Communicate clinical findings to provider
• Adherent to all regulatory requirements
• Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing
• Provide training and guidance to new and junior investigators
• Assist junior Investigators in identifying resources for cases; offer suggestions on investigative strategy
• Serve as back up to the Team Leader as necessary
• Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues
• Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings
• Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
• Communicate ideas on efficiency gains; provides input regarding controls for monitoring FWA among the business segments

Senior Analyst, Application Developer

Medical Director – Pain Management

Benefits Consultant

Supplemental Health Sales Executive

Supplemental Health Sales Executive

Digital Product Manager / Project Manager

Lead Director – Corporate Compliance

Senior Data Scientist

Senior Platform Engineer, Data & Performance Enablement

Case Manager, Registered Nurse - Field MI

Clinical Pharmacist, Clinical Account Operations

Patient Care Coordinator

Clinical Pharmacist – Prior Authorization

Senior Manager, Operational Excellence Analytics

Senior Investigator, Special Investigations Unit