Manager, Pharmacy Policy Management

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Spearhead the identification of new and emerging pharmacy policy opportunities across Commercial, Medicare, and Medicaid sectors.

• Create comprehensive business requirement documents for pharmacy policies.

• Convert policy intent into claims processing rules, workflows for utilization management, and reimbursement methodologies.

• Assist in the policy enablement processes.

• Ensure alignment of coding and reimbursement logic with the intent of Medical Pharmacy policies.

• Develop quality monitoring programs for the implementation and operational execution of Medical Pharmacy policies.

• Conduct root cause analyses for policy defects, configuration problems, coding inaccuracies, and operational failures.

• Maintain audit readiness and keep supporting documentation up to date.

• Create and track KPIs that support the effectiveness of Medical Pharmacy policies.

• Utilize data analytics to identify trends in utilization, operational gaps, coding flaws, and cost-saving opportunities.

• Assist with internal audits, external audits, compliance reviews, and initiatives for corrective actions.

• Foster operational excellence by minimizing policy-related defects and enhancing claim payment accuracy.

⛳️ Requirements

• Minimum of 3 years of experience in policy and business analytics.

• Certified Professional Coder (CPC), Certified Pharmacy Technician (CPhT), or commitment to obtain CPC within one year of employment.

• Proven experience collaborating with cross-functional stakeholders in clinical, operational, and technical areas.

• Ability to translate data analytics into actionable insights.

• Familiarity with specialty pharmaceuticals, provider-administered drugs, biosimilars, infusion therapies, and emerging therapeutic areas.

• Understanding of Medicare Part B drug management and reimbursement processes.

• Experience with specialty drug cost-management programs and affordability initiatives.

• Knowledge of Payment Integrity and platforms for medical drug claim editing.

• Bachelor’s degree in pharmacy, healthcare administration, or a related field, or an equivalent combination of education and relevant experience.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being, subject to eligibility.