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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 SummaryThe Care Plan Reviewer (Clinical Case Manager BH) utilizes advanced clinical judgment and criticalthinking skills to supports appropriate member behavioral healthcare through review of assessmentand care planning documentation and consultation with care coordinators to support psychosocialwraparound services to promote effective utilization of available resources and optimal, cost-effectiveoutcomes.As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, OhioRISE will help struggling children and their families by focusing on the individual with strongcoordination and partnership among MCOs, vendors, and ODM to support specialization in addressingcritical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinatedbehavioral health services for children with serious/complex behavioral health needs involved in, or atrisk for involvement in, multiple child-serving systems.Responsibilities include:· Be clinically and culturally competent/responsive with training and experience necessary toprovide clinical consultation for members complex need across child-serving systems.· Assessment of Member’s Child and Family-Centered Care Plans and Crisis and Safety Plan:o Through the use of clinical tools and information/data review, review assessments ofmember's needs and determines approach to meeting needs by evaluatingcomprehensiveness of member's Child and Family-Centered Care Plans.o Applies clinical judgment to the incorporation of strategies designed to reduce riskfactors and address complex clinical indicators which impact care planning andresolution of member issues.o Using advanced clinical skills, review crisis and safety plans for members experiencing abehavioral health need to support appropriate individualized trauma-informedinterventions and de-escalation strategies.· Enhancement of Medical Appropriateness and Quality of Care:o Application and/or interpretation of applicable criteria and clinical guidelines, policies,procedures, and regulatory standards while completing reviews and prior approvals toassess member's needs to ensure timely administration of benefits.o Using holistic approach consults with supervisors, Medical Directors and/or otherprograms to overcome barriers to meeting goals and objectives; presents cases at caseconferences to obtain multidisciplinary view in order to achieve optimal outcomes.o Identifies and escalates quality of care issues through established channels.o Ability to speak to medical and behavioral health professionals to influence appropriatemember care.o Utilizes motivational interviewing skills to provide coaching to care coordination staffand supervisors to support the child and family-centered care planning processconsistent with System of Care Principles and High-Fidelity Wraparound practice.o Provides coaching, information and support to empower the member to make ongoingindependent medical and/or healthy lifestyle choices.o Analyzes all utilization, self-report and clinical data available to consolidate informationand begin to identify comprehensive member needs. Required Qualifications· Unencumbered Behavioral Health clinical license in Ohio is required (LMFT, LSW, LPC).· 2+ years of experience in children's mental health, child welfare, developmental disabilities,juvenile justice, or a human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers.· Experience in one or more of the following areas of expertise: family systems, communitysystems and resources, case management, child and family counseling/therapy, childprotection, or child development.· 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, andMS Office Suite applications.· Willing and able to travel in-state up to 10% of the time with a personal vehicle. Preferred Qualifications· LPCC, IMFT, LISW licenses are preferred.· 3+ years of direct clinical practice experience post-Master's degree, e.g., hospital setting oralternative care setting such as ambulatory care or outpatient clinic/facility.· Managed care/utilization review experience.· Case management and discharge planning experience Education· Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy is requiredAnticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$54,095.00 - $116,760.00This 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: 06/16/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

CVSHealth

Care Plan Reviewer- OhioRISE

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 Well-being Coach role utilizes a collaborative process of assessment, planning, implementation, and evaluation to engage, educate, and promote members in decisions related to achieving and maintaining their optimal well-being.The goal is to support members in identifying and achieving their own personal goals across any of the six dimensions of wellness including physical, emotional, social, financial, purpose, and character strengths.Position Overview <ul> <li>This position provides coaching via telephone and televideo.</li> <li>The work hours for this position are Monday-Friday 11:30am-8:00pm Eastern Time.</li> <li>This position is fully remote, anywhere in U.S.</li> </ul>Key Responsibilities<ul> <li>Utilizing motivational interviewing and active listening skills.</li> <li>Provide coaching and support to empower the member to meet their personal wellness goals and sustain long-term positive behavioral change. </li> <li>Assess member’s appropriateness for coaching and coordination into other levels of care and/or resources as needed.</li> <li>Develop and monitor established plans of care, in collaboration with the member to meet the member’s goals.</li> </ul> Required Qualifications<ul> <li>1+ years of professional wellness/life coaching experience.</li> <li>1+ years of experience working with Medicare and/or aging population.</li> <li>Professional Coaching certification (Board Certified Coach[BCC], ICF-credential [ACC/PCC/MCC], or NBC-HWC).</li> <li>Excellent computer skills including MS Office applications such as Excel, Word, Teams and Outlook.</li> </ul> Preferred Qualifications<ul> <li>Experience across the six dimensions of well-being including physical, emotional, social, financial, purpose and character strengths.</li> <li>Demonstrated ability to communicate, problem solve, and work effectively with people, use good judgment in challenging situations.</li> <li>Experience in facilitating patient/client positive behavioral change.</li> <li>Ability to work with a multidisciplinary team.</li> <li>Background in motivational interviewing, active listening skills, Transtheoretical Model, mindfulness-based and other evidence-based coaching techniques.</li> <li>Bilingual Spanish speaking.</li> </ul> Education<ul><li>Bachelor's Degree in Wellness related field (e.g., Health ed, Wellness, Health Promotion, Behavioral Health) or equivalent work experience.</li></ul>Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$46,988.00 - $122,400.00This 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: 06/25/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Well-being Coach

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 SummaryUtilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.<ul> <li>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.</li> <li> 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</li> <li>Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs</li> <li>Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization</li> <li>Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.</li> <li>Typical office working environment with productivity and quality expectations.</li> <li>Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.</li> <li>Sedentary work involving periods of sitting, talking, listening.</li> <li>Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.</li> <li>Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.</li> <li>Effective communication skills, both verbal and written</li> </ul>Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence- Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management- Preference for those residing in ET, CT zones EducationAssociates Degree requiredBSN preferredAnticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$29.10 - $62.32This 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: 06/16/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Utilization Management Nurse Consultant

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 Mainframe Capacity Planning and Performance team is hiring for a Mainframe Performance Engineer. This engineer will be responsible for monitoring shared mainframe system resources, providing support to applications by running utilization reports, finding top consumers, reviewing trends/abnormalities, as well as running real time diagnostics. Strong technical, problem solving, and interpersonal skills are key to perform this role successfully. The role will require collaboration with multiple mainframe teams, assistance with design and QA testing, ongoing MIPS reduction efforts, and Open Enrollment/Welcome Season planning and support. On call support for application performance is expected.*This position is remote and can be based in any time zone in the U.S.Required Qualifications<ul> <li>7+ years of general mainframe experience: z/OS and z Hardware architecture</li> <li>5+ years of performance analysis and troubleshooting</li> <li>5+ years of experience with the Microsoft Suite</li> <li>3+ years of mainframe monitoring tools </li> </ul>Preferred Qualifications<ul> <li>3+ years of experience with DB2, CICS and/or MQ</li> <li>3+ years of experience with Omegamon, RMFIII</li> <li>3+ years of experience with SAS/MXG</li> <li>2+ years of experience in Retail, Pharmacy or Healthcare domain</li> <li>Informational Science, Computer Science, Computer Engineering or equivalent degree</li> <li>Strong work ethic, self-starter, and be able to be highly productive in a dynamic, collaborative environment</li> <li>Experience working with diverse teams, working across multiple time zones and geographies</li> <li>Ability to influence and inspire teams to align with the technical direction</li> </ul>EducationBachelor’s degree, or equivalent experience (HS diploma + 4 years relevant experience)Business OverviewBring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.Pay RangeThe typical pay range for this role is:$118,450.00 - $260,590.00 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: 07/11/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Mainframe Performance Engineer

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 SummaryDo things that matter. Diabetes, congestive heart failure, COPD, back pain, asthma, pulmonary fibrosis, chronic kidney disease, Alzheimer's, multiple sclerosis, cancer... everyone knows someone affected by these conditions. Our goal is to decrease cost and improve health for members with chronic disease. We do this by using data science and advanced analytics (e.g., condition specific predictive models and clinical data mining) to improve their care journeys and outcomes, focusing on the right members getting the right interventions at the right time. Mission aligned to improve health. With 1,000+ health hubs, 1,100+ minute clinics, 23M+ lives insured by Aetna, and 100M+ lives with pharmacy benefits coverage through Caremark. With this unique collection of assets, CVS Health has an unparalleled platform to make a significant impact on healthcare in the US and beyond. We have actual big data. The combined data assets of CVS are massive: medical and pharmacy claims, health care records, commercial store, and transactional data for 100M+ members. The scale of our data will allow you to design and test powerful experiments and challenge yourself to innovate in ways that others simply cannot. An elite team. You’ll be joining a team of MDs, PhDs, MBAs, and top analytics professionals that bring their clinical, technical, and economic experience to bear on some of the toughest targets in healthcare. Our PBM Analytics team is tasked with optimizing our ability to engage with our 100M+ Caremark members to help them make better healthcare decisions, particularly relating to the medications they take. Our goals are to improve clinical outcomes and to help members gain more transparency into the healthcare system so that they can save money and have better experiences. To do this we’ve developed a leading capability that combines data science, agile marketing, behavioral economics, large scale experimentation, and optimization of our digital capabilities. Through this we message millions of members each year about real challenges they face and help them become healthier or save money – we drive tangible and meaningful impact for our members. This role is required to<ul> <li>Develop and/or use algorithms and statistical predictive models and determines analytical approaches and modeling techniques to evaluate scenarios and potential future outcomes</li> <li>Perform analyses of structured and unstructured data to solve multiple and/or complex business problems utilizing advanced statistical techniques and mathematical analyses and broad knowledge of the organization and/or industry</li> <li>Collaborate with business partners to understand their problems and goals, develop predictive modeling, statistical analysis, data reports and performance metrics</li> <li>Develop and participate in presentations and consultations to existing and prospective constituents on analytics results and solutions</li> <li>Interact with internal and external peers and managers to exchange complex information related to areas of specialization</li> <li>Use strong knowledge in algorithms and predictive models to investigate problems, detect patterns and recommend solutions</li> <li>Use strong programming skills to explore, examine and interpret large volumes of data in various forms</li> </ul> Required Qualifications<ul> <li>3+ years of relevant analytic experience</li> <li>Experience programming using R or Python</li> <li>Experience in SAS or SQL</li> </ul>​Preferred Qualifications<ul> <li>Demonstrates strong ability to communicate technical concepts and implications to business partners</li> <li>Anticipates and prevents problems and roadblocks before they occur</li> <li>Strong knowledge of advanced analytics tools and languages to analyze large data sets from multiple data sources</li> <li>Demonstrates proficiency in most areas of mathematical analysis methods, machine learning, statistical analysis, and predictive modeling and in-depth specialization in some areas</li> <li>Foundational knowledge of PBM business functions, including underwriting, sales, product development, network management, and trade</li> </ul> EducationBachelor's degree or equivalent work experience in Mathematics, Statistics, Computer Science, Business Analytics, Economics, Physics, Engineering, or related discipline. Master’s degree or PhD preferredAnticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$83,430.00 - $222,480.00This 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: 06/20/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Senior Data Scientist - UM strategy and 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 SummaryAs a Member Communications Manager for CVS Health, you will oversee a team responsible for DMR Production. You will work closely with several teams, internally and externally, to ensure documents are accurate and mail on time per CMS requirements. You will be responsible for developing your team and constantly looking for process improvements. There will be multiple lines of business and processes that fall under the Enrollment Manager responsibility. You will need to be proactive in evaluating risks and preventing issues.To be a candidate for this you will possess the following:<ul> <li>Excellent interpersonal skills and ability to communicate and influence all levels in the organization</li> <li>Strong problem solving and critical thinking</li> <li>Ability to triage multiple requests</li> </ul>Required Qualifications<ul> <li>3+ years of leading direct reports</li> <li>Project Manager Experience</li> <li>Production Experience</li> <li>Quality Control Experience</li> </ul>Preferred Qualifications<ul> <li>5+ years of leading direct reports</li> <li>Short term and long term plans to improve process and find cost savings</li> </ul>Education<ul><li>Bachelor’s degree required; equivalent combination of education and experience may be considered</li></ul>Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$60,300.00 - $132,600.00This 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: 06/16/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Member Communications Manager

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 SummaryResponsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions.-Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria. -Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial. -Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process. -Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services. -Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response. -Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure. -Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise. -Identifies trends and emerging issues and reports on and gives input on potential solutions.-Ability to meet demands of a high paced environment with tight turnaround times. -Ability to make appropriate decisions based upon Aetna's current policies/guidelines. -Collaborative working relationships. -Thorough knowledge of member and/or provider appeals, complaints and grievance policies. -Strong analytical skills focusing on accuracy and attention to detail. -Knowledge of clinical terminology, regulatory and accreditation requirements. -Excellent verbal and written communication skills. -Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word. Required Qualifications-Experience in reading or researching benefit language. -1-2 years experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience. Preferred Qualifications -Experience in research and analysis of claim processing a plus. Education-Some college preferred. -High School or GED equivalent.Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$17.00 - $25.65This 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. 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.

Appeal and Grievance Coordinator - Prefer Candidate live in IL

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 The Network Relations Sr Analyst supports our Medicaid Provider Experience programs to maintain provider risk management and positive relationships supporting high value initiative activities with our Provider network. The Network Relations Sr Analyst will assist in driving coordination of internal and external solutions to achieve Best-in-Class provider satisfaction, affordability and quality improvements as set by each Medicaid Health Plan.<ul> <li>Deploy and support the Medicaid Provider Engagement program including onsite meetings at Aetna offices as required</li> <li>Reviews, learns and participates with operations teams regarding policy and procedures related to claims/providers.</li> <li>Assist with the monitoring of executed provider contracts to ensure Network Access meets State requirements</li> <li>Coordinates provider information with Provider Data Services including Member Services and other internal departments as requested as Provider Demographics are updated</li> <li>Supports providers by resolving problems and advising providers of new protocols, policies, and procedures</li> <li>Deliver training materials for staff and provider network. Participates as need for initial and ongoing provider in-services and provider education. </li> <li>Participates, when requested, in Grievance and Appeals meetings, and/or assists with tracking and trending provider grievances,</li> <li>Assists as requested for responses for all governmental, regulatory and quality assurance provider complaints; timely and continuous reconciliation of provider records; oversees Provider Access and Availability by reviewing Appointment Availability Audits conducted by staff</li> <li>Provides support and maintenance assistance for websites, portals, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters</li> <li>Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc. Coordinates provider status information with member services and other internal department</li> <li>Promotes and educate providers on cultural competency</li> </ul> Required Qualifications<ul> <li>Minimum of 3 to 5 years’ experience in Provider Relations; experience in Medicaid servicing or managing non-standard relationships with providers with exposure to benefit plan design and/or contract interpretation</li> <li>Excellent interpersonal skills and the ability to work with others at all levels </li> <li>Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals &amp; Disputes and Network Performance Standards</li> <li>Excellent problem-solving skills</li> <li>Strong communication skills</li> <li>Candidates are to reside within applicable state with ability to travel as needed to provider sites and Aetna office locations as required</li> </ul> EducationBachelor’s degree or an equivalent combination of formal education and experienceAnticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$46,988.00 - $122,400.00This 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: 07/02/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Senior Analyst, Network Relations

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 is a remote based (work from home) position for the New England Region. The preferred candidate will reside in Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine.Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. There will be some weekend and holiday call required as part of the New England Team. This will be scheduled well in advance and all of the Medical Directors will be a part of the rotation.The Medical Director will be responsible for overseeing the utilization review for health systems and providers in New England. An ideal candidate would have experience performing in-hospital utilization reviews and other quality activities. The Medical Director will be required to have a New England state medical license without encumbrances, or the ability to obtain the license within a reasonable timeframe. Collaboration and teamwork are the defining characteristics of The New England Medical Director team; in order to be a successful member of the team the candidate must exemplify these qualities. <ul> <li>As a Medical Director you will focus primarily on overseeing utilization review and quality assurance of inpatient hospitalizations, prior authorizations, and appeals.</li> <li>You will participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.</li> <li>You will support the Medical Management staff ensuring timely and consistent responses to members and providers. This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed. </li> </ul>Required Qualifications:*Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.*Active and current medical license without encumbrances*M.D. or D.O., Active and Current Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience. Preferred Qualifications:*Residence in one of the states in the New England Region*Previous UM experience with a Health Plan / Payor.*Previous UM experience as a Physician Advisor in a Health / Hospital system. *Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine Preferred. Education: *Medical Doctor or Doctor of Osteopathic MedicinePay 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: 08/28/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Medical Director - New England Region

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:In the role of Manager - Application Developer at CVS Health, you will be a pivotal member of our development team, interfacing with key stakeholders and applying your technical proficiency across various stages of the Software Development Life Cycle (SDLC). This includes engaging in Requirements Elicitation, Design, and Development. Your contributions will be crucial in ensuring the successful delivery of projects, as you will help the team produce high-quality code deliverables for specific modules. You will also lead validation efforts for all types of testing and support activities related to implementation, transition, and warranty. In this position, you will be responsible for conducting techno-functional impact analysis, as well as design and code construction activities associated with the development of software releases for the Omnicare business systems. Your strong technical, functional, and interpersonal skills will be essential for success in this role. The current suite of systems includes multiple Tier 1 applications. You will collaborate closely with the development manager, product management/owners, architects, quality assurance/testing teams, developers, and project managers to drive business change and innovation within our .NET-based business applications. Your involvement will span the entire development life cycle of a product, requiring you to deliver efficient solutions while identifying and mitigating any risks prior to deployment in production and supporting the applications afterwards. You will also play a significant role in customer interfacing, ensuring that project delivery aligns with client expectations. This position is designed for individuals who thrive in a collaborative environment and are committed to delivering high-quality software solutions that enhance the healthcare experience.Required Qualifications: <ul> <li>5+ years of professional IT experience</li> <li>3+ years of .NET experience, including ASP.NET, MVC, Webforms, Razor pages and C# or VB.NET</li> <li>3+ years of software development and requirement analysis, design experience</li> </ul>Preferred Qualifications: <ul> <li>Experience with Visual Studio, .NET, T-SQL and PL/SQL development</li> <li>Development experience for projects delivered via Agile, Waterfall, and/or SAFe methodologies</li> <li>.NET Core experience including Web API, Entity Framework, and Dependency Injection</li> <li>API design patterns experience (REST - XML, JSON)</li> <li>Knowledge in Azure cloud, specifically Azure App Services and Function Apps</li> <li>Proven track record of writing clean, high-quality, high-performing, scalable code</li> <li>Experience as a technical Subject Matter Expert (SME) in understanding business requirements and translating them into software solutions</li> <li>Production Support experience handling support tickets, change and off hour application support during maintenance and release activities as and when required</li> </ul>Additional Responsibilities:<ul> <li>Interface with key stakeholders throughout the Software Development Life Cycle (SDLC)</li> <li>Engage in Requirements Elicitation, Design, and Development phases</li> <li>Deliver high-quality code deliverables for specific modules</li> <li>Lead validation efforts for all types of testing</li> <li>Support activities related to implementation, transition, and warranty</li> <li>Conduct techno-functional impact analysis for software releases</li> <li>Collaborate with development managers, product management, architects, and project managers</li> <li>Drive business change and innovation in .NET-based applications</li> <li>Identify and mitigate risks prior to production deployment</li> <li>Interface with customers to ensure successful project delivery</li> <li>Provide IT support for applications on an as needed basis</li> </ul>Education:<ul><li>Bachelor’s degree or, equivalent experience (HS diploma + 4 years relevant experience)</li></ul>Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$83,430.00 - $166,860.00This 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.

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