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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.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.Position Summary At CVS Health, we are dedicated to building a world of health around every consumer, surrounded by passionate colleagues who are committed to transforming healthcare. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels, and a workforce of over 300,000 purpose-driven colleagues. We care for people where, when, and how they choose, in a way that is uniquely more connected, convenient, and compassionate. We do it all with heart, every single day.We are seeking a Senior Manager of Provider Contract &amp; Pricing Testing to join our expanding Testing Center of Excellence. This role requires a dynamic leader with extensive experience in provider and contract testing, test automation, and quality assurance. You will be responsible for managing a team of quality assurance engineers and analysts to implement and maintain effective testing processes, procedures, strategies, and automation tools for delivering high-quality provider contracts and pricing changes to our clients.Key Responsibilities:<ul> <li> Quality Leadership: Oversee the quality assurance of Provider Contracts and Pricing, ensuring that both Provider and Member Experiences meet or exceed expectations through the use of test automation tools.</li> <li> Automation: Collaborate with IT to support a robust testing automation framework for Provider &amp; Contract Testing, driving the adoption and optimization of automation tools and implementing innovative approaches using proven technologies.</li> <li> Team Development: Mentor and motivate team members to reach their full potential while promoting industry best practices in Quality Assurance and Testing.</li> <li> Sr Leadership Reporting: Deliver comprehensive quality reports on Provider &amp; Contract Testing outcomes, making informed recommendations and taking appropriate actions based on the data.</li> <li> Talent Development: Build a high-performing team by providing opportunities, guidance, and constructive feedback, while creating a talent pipeline for future growth.</li> <li> Technical Guidance: Set team direction, resolve challenges, and provide technical support to ensure development objectives are met.</li> </ul>Required Qualifications: The ideal candidate will possess a strong work ethic, be a self-starter, and thrive in a dynamic, collaborative environment. Key attributes include:<ul> <li>5+ years of experience managing quality assurance projects.</li> <li>5+ years of experience in provider contract testing, claims adjudication systems, quality assurance, or related functions.</li> <li>5+ years of experience in managing, collecting, and analyzing testing metrics for reporting and delivery.</li> <li>Proven program and project management experience, including the creation and management of integrated plans to ensure predictable outcomes.</li> <li>Experience leading large integrated project plans and driving IT development to meet specific business needs.</li> </ul>Preferred Qualifications:<ul> <li>Experience with commercial, individual exchange, and Medicare programs.</li> <li>Mastery of problem solving and decision-making skills</li> </ul>Education: Bachelor’s degree required or equivalent work experience.Pay RangeThe typical pay range for this role is:$82,940.00 - $182,549.00 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. This position also includes an award target in the company’s equity award program. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 05/31/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

CVSHealth

Sr. Manager, Provider Contract and Pricing Testing

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.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. Job Profile Summary The Senior Manager of Strategic Planning will be a highly dynamic role that will support the growth and development of Field Operations &amp; other key business units. The role will also be responsible for providing data analysis, crafting executive-level presentations, and other supporting materials within areas of expertise while developing new areas of expertise. The Senior Manager of Strategic Planning will apply in-depth knowledge of addressing resolutions of strategic operations initiatives with internal peers, external consultants, and cross-functional team members with minimal supervision. This role will also evaluate and develop new market initiatives and analyze business opportunities in both new and existing markets. Job Description A Brief Overview Plans and executes strategies to meet organization's long-range goals including clinic and KPI performance and growth. Evaluates and develops new market initiatives and analyzes business opportunities in both new and existing markets. Applies in-depth knowledge of addressing resolutions of strategic planning initiatives with internal peers, external consultants, and cross-functional team members with minimal supervision. What you will do <ul> <li>Acts as a top-level specialist to develop strategic plans that leverage key insights from the competitive environment, market research, industry analysis, and financial evaluation.</li> <li>Establishes and implements programs and innovative initiatives for the organization to advance Retail Health portfolio.</li> <li>Adapts the strategic plan to navigate market dynamics and trends in consumer behavior and maximize the potential of the organization.</li> <li>Advises departments on strategic partnerships, alliances, or acquisitions to drive growth and enhance organizational capabilities.</li> <li>Supports monthly business reviews, Objectives &amp; Key Results (OKR) processes, and field-level implementation of initiatives.</li> <li>Applies highly developed knowledge of scenario planning to anticipate potential clinic outcomes based on selected criteria.</li> <li>Promotes effective internal communications within the strategic planning department to facilitate the alignment of team processes and platforms with strategic objectives.</li> <li>Analyzes &amp; synthesizes large data sets and develops executive-level insights to inform clinical operations strategy, in collaboration with stakeholders.</li> <li>Cross-functionally collaborates with stakeholders (e.g. HR, Finance, Comms, Field Leaders, Product etc.) to drive initiatives forward.</li> <li>Establishes and implements programs and innovative initiatives for the organization to advance Retail Health portfolio, including but not limited to MinuteClinic (+ MC Primary Care), Enterprise Virtual Care/Behavioral Health &amp; Virtual Primary Care.</li> </ul> For this role you will need Minimum Requirements <ul> <li>7-10 years work experience</li> <li>Understanding of the general healthcare industry and how the healthcare system functions</li> <li>Adept at business intelligence &amp; advanced Excel skills (5+ years)</li> </ul> Education <ul> <li>Bachelor's degree preferred/specialized training/relevant professional qualification.</li> <li>Masters degree (MBA, MHA, MPH etc.) a plus</li> </ul> Pay RangeThe typical pay range for this role is:$82,940.00 - $182,549.00 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. This position also includes an award target in the company’s equity award program. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 04/28/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Senior Manager, Strategy and Business

Offers Advertiser Capabilities Manager, Shopping (Remote-Eligible)Summary: As a Business Analysis Manager at Capital One, you will apply your strategic and analytical skills to major company challenges. You'll team with world-class professionals to develop and test strategies that ultimately impact the bottom line. And you will do it all in a collaborative environment that values your insight, encourages you to take on new responsibility, promotes continuous learning, and rewards innovation. This product manager will own strategy and execution for building new advertiser campaigns for Capital One card and bank customers. This includes partnership with external brands and Shopping’s sales team to identify opportunities and build incredible customer experiences to unlock new customer savings opportunities. <ul> <li>Deeply analytical, including the ability to both do complex SQL and think in quantitative business frameworks</li> <li>Ability to build a tech roadmap and partner with engineering to execute via creation of detailed requirements</li> <li>Passion for building great customer experiences</li> <li>Strong communications to work across a wide range of partners to build strategy</li> </ul>General Responsibilities: <ul> <li>Strategic leadership: Develop business strategies that will drive growth, profitability, and competitive success for Capital One in the face of shifting consumer and regulatory demands </li> <li>Leadership: May manage and develop 1-2 analysts. Coaching and mentoring associates with a goal of developing and retaining talent at Capital One </li> <li>Product: Develop and implement new product and pricing strategies for various lending products; lead product level modeling/analytics </li> <li>Marketing: Lead direct-to-consumer marketing efforts for select products, and strategic intent for products distributed through the retail channel. Build targeted insights to inform the design and development of new customer experiences, as well as breakthrough technology and concepts designed to deliver on new go-to-market strategies </li> <li>Credit Risk: Drive step-change improvements in credit performance by connecting drivers of future consumer credit trends to historical behavior, creating risk models, and testing hypotheses using rigorous monitoring and analysis </li> <li>Execution: Manage and sequence delivery of business intent, build business requirements and execute against the product strategy. Oversee multiple projects and programs concurrently </li> <li>Partnership: Work closely with colleagues across Capital One including: IT, Sales, Operations, Finance and others to drive improvement in quality, volume, service, and profitability </li> <li>Strategic &amp; analytic orientation: A proven track record of decision making and problem solving based on analytics. Conceptual thinking skills must be complemented by a strong quantitative orientation, given that a large part of the business is based on rigorous analytic marketing &amp; credit risk management </li> <li>Strong business judgment, leadership and integrity: He/she should be a tenacious decision maker, able to bring a healthy, aggressive, yet responsible approach to business </li> <li>Solid people leadership experience: Ability to build and leverage the capabilities of a high-performing team, as well as business partners across the enterprise. He/she should foster innovation, drive critical decisions, hold business partners accountable, and be able to consistently deliver results </li> <li>Strong executive communication skills: Impeccable written and oral communication credentials, coupled with strategic influencing skills and the ability to drive agreement through intellect, interpersonal and negotiation skills </li> <li>Clear results orientation: display an intense focus on achieving both short and long term goals. He/she should be able to drive and execute an agenda in an uncertain and fluid environment </li> <li>Successful track record of thriving in a fast paced, entrepreneurial and dynamic environment. Previous consulting experience is a plus </li> </ul>Capital One is open to hiring a Remote Employee for this opportunity.Basic Qualifications: <ul> <li>Bachelor’s Degree in any quantitative field (Business, Math, Economics, Finance, Statistics, Science, Engineering) </li> <li>At least 2 years of experience in analysis </li> <li>At least 2 years of experience in SQL querying</li> </ul>Preferred Qualifications: <ul> <li>Master’s Degree in Business or quantitative field such as Finance, Economics, Physical Sciences, Math, Statistics, Engineering </li> <li>5+ years of experience in analysis </li> <li>3+ years of experience in SQL querying</li> <li>2+ years of experience in financial services </li> <li>1+ year of experience in consulting </li> <li>2+ years of experience in people management </li> </ul>Capital One will consider sponsoring a new qualified applicant for employment authorization for this position. The minimum and maximum full-time annual salaries for this role are listed below, by location. Please note that this salary information is solely for candidates hired to perform work within one of these locations, and refers to the amount Capital One is willing to pay at the time of this posting. Salaries for part-time roles will be prorated based upon the agreed upon number of hours to be regularly worked.McLean, VA: $158,400 - $180,800 for Business Manager New York, NY: $172,800 - $197,200 for Business Manager Remote (Regardless of Location): $144,000 - $164,400 for Business Manager Candidates hired to work in other locations will be subject to the pay range associated with that location, and the actual annualized salary amount offered to any candidate at the time of hire will be reflected solely in the candidate’s offer letter.This role is also eligible to earn performance based incentive compensation, which may include cash bonus(es) and/or long term incentives (LTI). Incentives could be discretionary or non discretionary depending on the plan.Capital One offers a comprehensive, competitive, and inclusive set of health, financial and other benefits that support your total well-being. Learn more at the <a href="https://www.capitalonecareers.com/benefits" target="_blank">Capital One Careers website</a>. Eligibility varies based on full or part-time status, exempt or non-exempt status, and management level.This role is expected to accept applications for a minimum of 5 business days.No agencies please. Capital One is an equal opportunity employer committed to diversity and inclusion in the workplace. All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth or related medical conditions), race, color, age, national origin, religion, disability, genetic information, marital status, sexual orientation, gender identity, gender reassignment, citizenship, immigration status, protected veteran status, or any other basis prohibited under applicable federal, state or local law. Capital One promotes a drug-free workplace. Capital One will consider for employment qualified applicants with a criminal history in a manner consistent with the requirements of applicable laws regarding criminal background inquiries, including, to the extent applicable, Article 23-A of the New York Correction Law; San Francisco, California Police Code Article 49, Sections 4901-4920; New York City’s Fair Chance Act; Philadelphia’s Fair Criminal Records Screening Act; and other applicable federal, state, and local laws and regulations regarding criminal background inquiries.If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation, please contact Capital One Recruiting at 1-800-304-9102 or via email at <a href="#">RecruitingAccommodation@capitalone.com</a>. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodations.For technical support or questions about Capital One's recruiting process, please send an email to <a href="#">Careers@capitalone.com</a>Capital One does not provide, endorse nor guarantee and is not liable for third-party products, services, educational tools or other information available through this site.Capital One Financial is made up of several different entities. Please note that any position posted in Canada is for Capital One Canada, any position posted in the United Kingdom is for Capital One Europe and any position posted in the Philippines is for Capital One Philippines Service Corp. (COPSSC).

Capital One

Offers Advertiser Capabilities Manager, Shopping (Remote-Eligible)

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.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.Position SummaryThis position will be on the Aetna Voluntary Underwriting team and is responsible for new business and renewal underwriting for Accident, Hospital Indemnity Protection, and Critical Illness products. The Senior Manager will administer strategy for Underwriting to support the organization’s financial and strategic goals, ensuring underwriting decisions are consistent, effective, and compliant.Key Responsibilities:<ul> <li> Strategic Planning &amp; Administration:<ul> <li>Contribute to the planning and administration of company programs and initiatives that promote the Underwriting area’s agenda.</li> <li>Implement organizational policies, goals, and objectives based on best practices in the field.</li> </ul> </li> <li> Underwriting Methodology:<ul> <li>Develop methodology to underwrite voluntary benefits products within established requirements to ensure profitability and achieve a consistent loss ratio target.</li> <li>Align management of large new and renewal group quotations to underwrite profitable business for the region.</li> </ul> </li> <li> Analysis &amp; Reporting:<ul> <li>Deliver analysis and reporting on underwriting key performance indicators and recommend actions for improvement.</li> <li>Advise on competitor activity, third-party activity, and changes in law that may affect underwriting performance.</li> </ul> </li> <li> Product Development:<ul><li>Participate in the design of new voluntary benefits products, ensuring they meet market needs and profitability targets.</li></ul> </li> <li> Team Management:<ul> <li>Manage operational aspects of the team, including budget, performance, and compliance.</li> <li>Implement workforce and succession plans to meet business needs.</li> </ul> </li> </ul> Required Qualifications<ul> <li>7 to 10 years of experience in underwriting.</li> <li>3 to 5 years experience in underwriting voluntary benefits products, including Accident, Hospital Indemnity Protection, and Critical Illness.</li> <li>Proven track record of developing and implementing underwriting strategies that drive profitability and growth.</li> </ul> Preferred Qualifications<ul> <li>Demonstrated ability to develop and execute long-term strategic plans that align with organizational goals.</li> <li>Experience in driving innovation and implementing new initiatives to enhance underwriting processes and product offerings.</li> <li>Experience in collaborating with sales, marketing, and customer service teams to develop and promote customer-focused underwriting solutions.</li> <li>Strong interpersonal skills and the ability to build and maintain relationships with key stakeholders, including clients, brokers, and consultants.</li> <li>Experience in leveraging technology to streamline underwriting processes and improve efficiency.</li> </ul> Education<ul><li>A bachelor’s degree from an accredited institution is required. Preferred fields of study include business administration, finance, economics, mathematics, or a related discipline. An advanced degree (MBA, Master’s) is a plus.</li></ul>Pay RangeThe typical pay range for this role is:$67,900.00 - $199,144.00 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. This position also includes an award target in the company’s equity award program. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 06/29/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Underwriting Tech Lead

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.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.Position Summary This position will support clients in the Central and Eastern time zones.Plans, monitors and manages internal projects from initiation through completion. Secures required resources and uses formal processes and tools to manage resources, budgets, risks and changes. Manages projects to ensure on-time completion according to specifications and within budgeted costs. At the higher levels, incumbents manage large multifaceted projects; at lower levels, incumbents may be concerned with clearly identifiable elements or functions within a larger project. Typically incumbents matched to this function are working towards or have achieved certification in project management.What you will do<ul> <li>Acts as a top-level specialist on project and program planning and develops comprehensive program plans that encompass objectives, deliverables, timelines, and resource allocation.</li> <li>Adapts project and program plans to ensure alignment with business objectives and reinforce organizational standards.</li> <li>Applies highly developed knowledge of financial management principles to manage cost estimation, tracking, and budget reporting for programs and projects.</li> <li>Coaches junior-level project and program managers on how to utilize key performance indicators (KPIs) to measure progress and analyze project and program outcomes.</li> <li>Coordinates knowledge sharing among project teams to highlight success stories and improve project and program management practices through insights.</li> <li>Creates a continuous improvement plan for the project and program department to enhance delivery processes and outcomes.</li> <li>Designs the change management protocol to effectively respond to obstacles that may arise during project and program lifecycles.</li> <li>Utilizes data visualization tools and techniques to present project and program data in a visually appealing easily understandable format.</li> <li>Participates in project/program team training and development activities to enhance project management skills and knowledge.</li> </ul> Required Qualifications<ul> <li>5-10 years of managed care experience</li> <li>Adept at problem solving and decision making skills</li> <li>Adept at collaboration and teamwork</li> <li>Adept at growth mindset (agility and developing yourself and others) skills</li> <li>Adept at execution and delivery (planning, delivering, and supporting) skills</li> <li>Adept at business intelligence</li> </ul>Preferred Qualifications or Knowledge of:<ul><li>Preferred experience with HRP, ACAS, EPDB, MedCompass</li></ul> Education Bachelor's degree or equivalent experiencePay RangeThe typical pay range for this role is:$75,400.00 - $165,954.00 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. This position also includes an award target in the company’s equity award program. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 05/04/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Senior Manager, Project Program Management

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.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.Position Summary CVS Health, a Fortune 6 company, has an outstanding opportunity for a Medical Director (Medical Affairs).This is a remote based, work from home opportunity. The Medical Affairs department provides clinical business support to the entire enterprise and provides clinical oversight and mentorship for CVS Health clinical programs, PBM Clinical Quality activities, consultative support to the P&amp;T process, formulary development, drug information services and pipeline activities, and provision of clinical leadership to various internal departments (e.g., specialty pharmacy services, clinical product development, Enterprise Analytics, Compliance, Legal, Accreditation) and clients. The Medical Director (Medical Affairs) will report into the Medical Affairs Department and is responsible for clinical support and consultative activities across the PBM. In this role you may provide consultative clinical support to Account Management in support of Key Clients as assigned. The Medical Director transacts Utilization Management UM activities (prior authorization and appeals) and responds to prescriber inquiries related to UM transactions and more generally related to CVS Health coverage policies. Medical Directors at CVS Health are encouraged to model the highest levels of clinical integrity, knowledge and cross functional thinking and decision making. Medical Directors represent the clinical decision making and professional thought process of the prescriber as a partner across the enterprise’s decisions and planning. – Each Director is responsible for providing oversight of a portion of CVS Health's clinical programs and commercial client program support. Will share in reviews of utilization management (PA) criteria and clinical policy revisions/reviews. – Directors will spend a portion of most days completing assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate. – Medical Directors will participate in inter-rater review activities and other quality oversight processes for internal Director UM decisions. If specifically assigned to one business segment (i.e., Medicare clients), each director will become sufficiently skilled in various UM programs to support other segments (including commercial and Medicaid) on evening and weekend coverage. –In this role you'll perform a share of special clinical investigations and research as requested by the Senior Medical Director, Medical Affairs. These projects can include brief reviews of published literature around specific pharmaceutical questions or more in-depth projects requiring collaboration with pharmacists within Medical Affairs and in business units outside of the Department. CVS Health, a Fortune 4 company, has an outstanding opportunity for a Medical Director (Medical Affairs). Required Qualifications * Family Medicine or Internal Medicine Board Certification.* Minimum of 5 years clinical experience in direct patient care. * 2 or more years proven experience in clinical outcomes, with a solid understanding of medical statistics, regulatory agencies, and analytic programs * Unrestricted license to practice medicine in the state in which the candidate is located. Preferred Qualifications * Combination of five years of management and/or clinical experience in a managed care environment and health administration, including adequate clinical experience in direct patient care and working with professionals at different levels as a teammate (e.g., RNs, PharmDs, etc.). * ABMS or AOA Board Certified in a recognized medical specialty, preferably in a Primary Care field (Internal medicine, Family Medicine) * Master’s Degree in Public Health Administration or MBA preferred, UM/QA certification desired * Proficiency in MS Office Suite Education * Must be graduate of an accredited Medical School and Residency Program * Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia * Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employmentPay RangeThe typical pay range for this role is:$174,070.00 - $374,920.00 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. This position also includes an award target in the company’s equity award program. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 06/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Medical Director (Medical Affairs)

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.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.Position SummaryThe Professional Prod Pharmacist must have expertise and knowledge of the Pharmacy claims appeal process and the various applications used in the appeal process to comply with state bill requirements. In this role, you will be responsible for reviewing and resolving MAC appeals, developing and implementing solutions individually, and being a lead working with IT to automate solutions for complex requirements unique to states with pharmacy bills. This also includes being the appeals team SME in understanding the impact of appeal related issues and resolving them under tight TATs to remain in compliance. The Professional Prod Pharmacist is also responsible for creating reports required to monitor appeal bill compliance, satisfying client reporting requirements for appeals, as well as developing and ensuring the accuracy of appeal reporting as required by state agencies. This role requires a thorough knowledge of claim adjudication in order to perform research, internal claim related processes, and being a leader working with other internal business units to develop new solutions to meet the ever-increasing number of complex pharmacy bill compliance requirements. The position will be responsible for quality control process to ensure compliance.What you will do<ul> <li>Review and resolving MAC appeals</li> <li>Leads with strategic leadership and guidance to pricing teams, ensuring effective response to pharmacy and state department of insurance (DOI) appeals are effectively reviewed and responded.</li> <li>Partner with legal to disposition pharmacy complaints and appeals that come through state agencies</li> <li>Leads and owns the process and work instruction documents that comply with state laws and meets CVS compliance</li> <li>Leads and participate in state appeals audit and exam. Provides the information to state DOI on the inquiries.</li> <li>Interprets and drafts responses to state DOI inquiries and works with CVS legal team to respond to inquiries.</li> <li>Collaborates cross-functionally with legal, compliance, network and other teams to manage the pricing appeals.</li> <li>Counsels and mentor pricing team members, providing guidance and support to enhance their pricing skills and professional development.</li> <li>Delivers pricing solutions and recommendations that drive profitability and revenue optimization and contribute to the overall financial success of the organization.</li> </ul>This is a remote role open to qualified candidates within the United States. Required Qualifications<ul> <li>5+ years relevant work experience</li> <li>2+ years demonstrated experience in managed care (PBM) environment</li> <li>Familiarity with wholesaler invoices</li> <li>Demonstrated ability to work under tight deadlines</li> <li>Excellent Communication, interpreting, writing and leadership skills</li> <li>Ability to prioritize, organize, and manage DOI requests</li> </ul> Preferred Qualifications<ul> <li>1+ years’ experience with all Pharmacy and state department of insurance appeal related processes and state regulations, and claims adjudication, including claims adjudication logic</li> <li>Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal</li> <li>Adjudication system experience</li> <li>Strong mathematical problem-solving skills</li> <li>Prior PBM Knowledge</li> </ul> Education<ul> <li>BS in Pharmacy or Pharm D</li> <li>Current Pharmacist License in good standing, based on applicable state licensing requirements.</li> </ul>Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$94,500.00 - $211,200.00This 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. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 04/23/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Clinical Pharmacist, Pharmacy Appeals

<h3> Position Summary </h3> As a Senior Risk Specialist, Insider Risk Program, you will join a fast-paced, highly visible team charged with protecting the brand and reputation of the Deloitte US Firm. The Insider Risk team leverages cutting-edge technologies to detect, deter, and mitigate against all types of insiders. As a part of the team, you will be responsible for identifying high-risk behaviors, supporting training initiatives, and offering innovative solutions to protect the Firm’s most valuable assets. Recruiting for this role ends on May 16th, 2025. Work you’ll do Key responsibilities of this position include protecting Deloitte people, data, and information systems by leveraging a User Behavioral Analytics Tool to investigate insider threat risk indicators: <ul> <li>Apply program management skills to contribute to the daily operations of a mature insider threat program.</li> <li>Support highly visible, small team in day-to-day responsibilities: conduct data analysis, develop reporting and presentation content.</li> <li>Conduct in depth analysis of information received from various data sources: assemble, correlate, evaluate, and assess information concerning insider threats to personnel, confidential information, and information systems.</li> <li>Technical application: leverage a user behavioral analytics tool to develop a holistic understanding of potential high-risk employee behavior.</li> <li>Enhance the tool: research, organize, and facilitate data ingestion for new data feeds including data field mapping.</li> <li>Ability to troubleshoot the root causes of issues, develop solutions, document, and communicate findings.</li> <li>Conduct testing across multiple environments to validate new functionality or fixes for issues.</li> </ul> The successful candidate will possess: <ul> <li>Ability to work in multidisciplinary environment: collaborate with a variety of stakeholders to resolve investigations and mitigate risk.</li> <li>Strong written and presentation skills: develop briefings for key stakeholders based on trend analysis and identifying new opportunities for program maturation.</li> <li>Technical aptitude and willingness to learn.</li> <li>Possess high quality analytical, investigative, and problem-solving skills.</li> <li>Excellent verbal and written business communication skills.</li> <li>Excellent organizational and time management skills.</li> <li>Attention to quality and detail a must.</li> <li>Ability to apply critical thinking in evaluating different scenarios.</li> <li>Ability to handle confidential and sensitive information with appropriate discretion.</li> <li>Ability to prioritize work and operate independently; know when to seek guidance.</li> <li>Ability to organize and manage multiple projects simultaneously.</li> </ul> The team The Insider Risk Program resides within the Deloitte U.S. Firm’s Confidentiality and Privacy Office. The Confidentiality and Privacy Office is part of the Risk and Brand Protection organization within Deloitte LLP The Insider Risk Program is a part of Deloitte’s Enabling Areas within the Risk and Brand Protection group under Confidentiality and Privacy. This role is not client facing; we support our client-facing professionals in delivering high-quality trusted service to our clients. Qualifications Required: <ul> <li>Bachelor’s Degree is required</li> <li>Understanding of insider threat principles, programs, and analytical work</li> <li>Background or exposure to investigative processes</li> <li>Experience with technical implementation, data source ingestion, testing, and/or systems operations</li> <li>Exposure to cyber security applications, tools, and/or software </li> <li>Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future</li> <li>Ability to travel 0-10%, on average, based on the work you do and the clients and industries/sectors you serve</li> </ul> Preferred: <ul> <li>SDLC, agile methodology, and implementations</li> <li>Experience in confidentiality, privacy, or security fields</li> <li>Experience with O&amp;M or troubleshooting issues</li> <li>Experience or use of Behavioral Analytical tools</li> <li>Knowledge of integrating data feeds and validating data ingestion</li> <li>Ability to conduct detailed testing and understanding of testing cycles</li> </ul> Information for applicants with a need for accommodation: <a href="https://www2.deloitte.com/us/en/pages/careers/articles/join-deloitte-assistance-for-disabled-applicants.html" target="_blank">https://www2.deloitte.com/us/en/pages/careers/articles/join-deloitte-assistance-for-disabled-applicants.html</a> The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Deloitte, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $66,200-$121,800. You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance. Recruiting tips From developing a stand out resume to putting your best foot forward in the interview, we want you to feel prepared and confident as you explore opportunities at Deloitte. <a href="https://www2.deloitte.com/us/en/pages/careers/topics/recruiting-tips.html" target="_blank">Check out recruiting tips from Deloitte recruiters.</a> Benefits At Deloitte, we know that great people make a great organization. We value our people and offer employees a broad range of benefits. <a href="https://www2.deloitte.com/us/en/pages/careers/articles/life-at-deloitte-benefits-and-rewards.html" target="_blank">Learn more about what working at Deloitte can mean for you.</a> Our people and culture Our inclusive culture empowers our people to be who they are, contribute their unique perspectives, and make a difference individually and collectively. It enables us to leverage different ideas and perspectives, and bring more creativity and innovation to help solve our client most complex challenges. This makes Deloitte one of the most rewarding places to work. Our purpose Deloitte’s purpose is to make an impact that matters for our clients, our people, and in our communities. We are creating trust and confidence in a more equitable society. At Deloitte, purpose is synonymous with how we work every day. It defines who we are. We are focusing our collective efforts to advance sustainability, equity, and trust that come to life through our core commitments. <a href="https://www2.deloitte.com/us/en/pages/about-deloitte/articles/purpose-at-deloitte-us.html" target="_blank">Learn more about Deloitte's purpose, commitments, and impact.</a> Professional development From entry-level employees to senior leaders, we believe there’s always room to learn. We offer opportunities to build new skills, take on leadership opportunities and connect and grow through mentorship. From on-the-job learning experiences to formal development programs, our professionals have a variety of opportunities to continue to grow throughout their career.

Deloitte

Insider Risk Sr Specialist

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.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.<h2>Position Summary</h2>Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members, who are enrolled in Care Management and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand our Care Management Programs to change lives in new markets across the country.The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. Under the direction of a Registered/Licensed RN, the TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by:<ul> <li>Complete post-discharge questionnaire, which may be market specific.</li> <li>Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications.</li> <li>Benefit education</li> <li>Monitor members in low CM level for alerts or changes in condition to be transitioned back to RN.</li> <li>Complete post discharge call and required assessments (RAP), medication reconciliation (if within scope of practice), fall assessment if fall risk identified.</li> <li>Complete inpatient confinement calls and monitoring for discharge.</li> <li>Management of warm transfers form concierge and engagement hub</li> <li>Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)</li> <li>Evaluation of health and social indicators</li> <li>Identifies and engages barriers to achieving optimal member health.</li> <li>Uses discretion to apply strategies to reduce member risk.</li> <li>Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage.</li> <li>Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up.</li> <li>Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.</li> </ul>Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Focus assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.Job Responsibilities Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines.Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions.Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community.Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.<h2>Required Qualifications</h2><ul> <li>This position is a REMOTE position but the candidate must reside in either New Jersey Compact or New York</li> <li>2+ years LPN nursing experience</li> <li>Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses</li> <li>Discharge planning</li> <li>Advanced proficiency in Microsoft Word, Excel, and Outlook</li> <li>Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care</li> <li>Effective verbal and written communication skills</li> </ul><h2>Preferred Qualifications</h2><ul><li>Bilingual (English and Spanish)</li></ul> <h2>Education</h2> <ul> <li>High School Diploma/GED or equivalent experience (REQUIRED)</li> <li>Licensed Practical Nurse (LPN) (REQUIRED)</li> <li>Associate's Degree or Bachelor's Degree (PREFERRED)</li> </ul> Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$24.64 - $53.53This 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. 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.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 04/14/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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