<p>At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.</p> <p>As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.</p> <p>Position Summary</p> <p>As a Healthcare Compliance Senior Analyst, you will ensure contractual and regulatory compliance as it relates to third party programs. You will act as a liaison between internal departments and external contacts such as health plans, processors, pharmacy benefit managers (PBM), and governmental agencies. Additionally, you will facilitate the initiation and on-going maintenance of pharmacy system to ensure that CVS pharmacies are able to service and bill prescriptions for patients of third-party programs, where CVS is contracted and/or enrolled.</p> <p>Responsibilities:</p> <p>Third Party Information Management</p> <ul> <li>Make informed decisions by thoroughly reviewing communications distributed by PBMs, processors, health plans, state Medicaid and Medicare, relative to prescription and/or medical claim processing </li><li>Serve as a subject matter expert for both internal and external representatives by researching prescription insurance program requirements, medical billing policies, compliance inquiries, and related issues/complaints, and crafting timely responses </li><li>Demonstrate care by proactively identifying and resolving potential Third-Party operational issues </li><li>Understand the terms of Payer contracts, and NCPDP Standards, to ensure CVS and plan compliance </li><li>Translate, and clarify where needed, payer information and communicate to appropriate internal personnel, field management, and CVS pharmacy locations </li><li>Compose third party articles for the Payer Relations Weekly Update, issue emergency communications via the pharmacy HUB, and post Medicaid related third party program requirements on the Intranet, as necessary </li></ul> <p>Relationship Building</p> <ul> <li>Foster and maintain a professional effective working relationship with contracted agencies, PBMs, and health plans </li><li>Problem solving point of contact for complaints and inquiries received from payers on behalf of our mutual customers </li><li>Collaborate with payers, internal departments, and field personnel, to implement process improvements for prescription and/or medical claim processing, to ensure program compliance and to enhance store level customer service </li><li>Keep Payer Relations Contracting Directors and/or appropriate management apprised of problematic Payer related issues that may significantly impact prescription processing </li></ul> <p>Plan Code Facilitation</p> <ul> <li>Evaluate third party information to determine if an internal system update is required </li><li>Track plan changes via database, and prepare necessary documentation to facilitate new third-party plan codes and/or updates to existing codes </li><li>Collaborate with appropriate internal Payer Relations team(s) to determine best approach for system updates, when needed </li></ul> <p>Team Work</p> <ul> <li>Focus on the customer by addressing prescription processing escalations received from various internal departments and pharmacy teams </li><li>Contribute to a high-performing team by looking for opportunities to achieve individual and broader team goals, while remaining flexible for changing business needs, to enable supportive, collaborative, and management of challenging work </li><li>Assist with implementation of procedures, policies, and other projects as needed, to develop processes for efficient day to day payer and customer support </li></ul> <p>Our ideal candidate is someone who has excellent verbal and written communication skills, has a strong attention to detail with flawless execution, thinks independently and can offer solutions. We also look for someone with professionalism, the ability to problem solve, multi-task, excellent organizational skills, how-to prioritize their book of business and a proven ability to collaborate with both internal and external representatives.</p> <p>This is a hybrid opportunity seeking talent in the Rhode Island, Massachusetts, and Connecticut area that can travel into the office 3 days per week (Tuesdays, Wednesdays, Thursdays).</p> <p>Required Qualifications</p> <p>3+ years of experience in the pharmacy industry with knowledge of standard contract terms and conditions, best practices, and business policies</p> <p>Preferred Qualifications</p> <ul> <li>Knowledge of Pharmacy Benefit Management is a plus </li><li>Bachelor's Degree preferred </li><li>Demonstrated ability to think strategically, act tactically, and deliver outcomes </li><li>Organized and detail-oriented, with the ability to manage multiple tasks simultaneously and adjust priorities as needed, demonstrating high level of independent judgment and proactivity </li><li>Self-starter with strong interpersonal and leadership skills. Demonstrated ability to effectively influence other business areas in a matrixed complex organization </li></ul> <p>Education</p> <p>High School Diploma or Equivalent work experience</p> <p>Anticipated Weekly Hours</p> <p>40</p> <p>Time Type</p> <p>Full time</p> <p>Pay Range</p> <p>The typical pay range for this role is:</p> <p>$46,988.00 - $112,200.00</p> <p>This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p> <p>Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p> <p>Great benefits for great people</p> <p>We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:</p> <ul> <li> <p>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</p> </li><li> <p>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</p> </li><li> <p>Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</p> </li></ul> <p>For more information, visit https://jobs.cvshealth.com/us/en/benefits</p> <p>We anticipate the application window for this opening will close on: 03/21/2025</p> <p>Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p>