Job Description As a Client Specific Claim Audit Project Manager, you will become a subject matter expert with client Performance Guarantees. You will administer team audit programs, maintain and ensure adherence with state audit laws and federal regulations, conduct pharmacy outreaches, and finalize and send audit results. You will work with internal and external partners to ensure all areas of Performance Guarantees are met on a quarterly basis. Additionally, you will become familiar with the claim adjustment process and ensure process is compliant with client Performance Guarantees.
The claim adjustment process includes working with internal and external partners to modify and adjust claims with Performance Guarantees' time requirements. In this position, you will need to interpret CMS Guidance, understand Caremark's audit program, understand client's benefit design translates into claim adjudication, translate state audit laws, use these factors to make decisions to protect the client and execute the PG to perfection. To be successful in this role, you will need to think independently and have a high level of attention to detail. This position is client facing and this audit process keeps CVS/Caremark in compliance with Performance Guarantees. Required Qualifications - 1+ years of professional experience, preferably in a claims processing, a pharmacy setting, PBM or analytics role. Preferred Qualifications- 2+ years of professional experience, preferably in a claims processing, a pharmacy setting, PBM, or analytics role.
- Knowledge of pharmacy claims processing
- Knowledge of PBM industry
Education - Verifiable High School Diploma or GED required. Bachelor's Degree preferred.
CVS Health, through our unmatched breadth of service offerings, is transforming the delivery of health care services in the U.S. We are an innovative, fast-growing company guided by values that focus on teamwork, integrity and respect for our colleagues and customers. What are we looking for in our colleagues? We seek fresh ideas, new perspectives, a diversity of experiences, and a dedication to service that will help us better meet the needs of the many people and businesses that rely on us each day. As the nation’s largest pharmacy health care provider, we offer a wide range of exciting and fulfilling career opportunities across our three business units – MinuteClinic, pharmacy benefit management (PBM) and retail pharmacy. Our energetic and service-oriented colleagues work hard every day to make a positive difference in the lives of our customers.
CVS Health is an equal opportunity employer. We do not discriminate in hiring or employment against any individual on the basis of race, ethnicity, ancestry, color, religion, sex/gender (including pregnancy), national origin, sexual orientation, gender identity or expression, physical or mental disability, medical condition, age, veteran status, military status, marital status, genetic information, citizenship status, unemployment status, political affiliation, or on any other basis or characteristic prohibited by applicable federal, state or local law. CVS Health will consider qualified job candidates with criminal histories in a manner consistent with federal, state and local laws. CVS Health will not discharge or in any other manner discriminate against any Colleague or applicant for employment because such Colleague or applicant has inquired about, discussed, or disclosed the compensation of the Colleague or applicant or another Colleague or applicant. Furthermore, we comply with the laws and regulations set forth in the following EEO is the Law Poster: EEO IS THE LAW
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CVS Health does not require nor expect that applicants disclose their compensation history during the application, interview, and hiring process.
For inquiries related to the application process or technical issues please contact the Kenexa Helpdesk at 1-855-338-5609. For technical issues with the Virtual Job Tryout assessment, contact the Shaker Help Desk at 1-877-987-5352. Please note that we only accept resumes via our corporate website: https://jobs.cvshealth.com/