Job DescriptionResponsible for the quality of deliverables for particular client in Medicare, Medicare & Commercial benefits from CVS Health. Lead, monitor, manage TCOE Test Deliverables at enterprise management level which also extend the role of being a SME and involves widely in risk assessment to the core adjudication programs, monitoring/managing welcome season deliverables and implementations for all projects of all CVSH Book of Business (Medicare, Medicaid & Commercial). Responsible for validation of Global CMS changes for 2017 and provide the results for Medical Affairs & CMS approval and ensure all the Med D (Medicare) clients are in compliance with CMS Standards. Lead the TCOE team by creating test plans, test strategy, approach,project plan updates on test deliverables for different lines of business including Medicare, Medicaid and commercial, understanding the client requirements, complexity of the benefits and clinical setups. Build adjudication logic of business critical functionalities for client like SAM (Stand Alone Module), TOC (Transition of Coverage), XREF (Cross Reference), FML (Follow Me Logic) and Specialty (SRX) which are currently used across all lines of the business. Support, analyze, and address the business andmember impacts for the above mentioned functionalities and adjudication logicin claim processing whenever there is an issue in production. Review all the test artifacts including test scenarios, cases and make sure that core functionalities/benefits including Days Supply, Copay, Accumulation phases,Vaccine, DESI, DAW recovered across all the delivery channels like Retail, ALF, HIF, Mail, Preferred Benefits, INN (In Network) and OON (Out of Network).Validate the claims and make sure the copay is calculated across all the accumulation phases for Med D (DED, ICL, GAP, and CAT) and also ensure the benefits setup for the plan satisfy CMS Compliance. Validate the test artifacts across all the lines of business and make sure it has all the drugs including Brand, Generic, Preferred Brand/generic, OTC’s, Specialty and vaccine drugs. Serve as Point of Contact for the technical deliverables including AEP (Annual Enrolment Plans), BIPV (Business Integration process Validation), Joint ventures, Medicaid State Implementations, and MMP (Medicare, Medicaid Plans Yearly Implementations) and closely work with client from requirements analysis for Annual Enrolment, Products, Eligibility & benefits and gather the In Scope and Out of Scope of the yearly and monthly TCOE deliverables. Responsible for CMS/State deliverables like Encounter file and CET’s and ensure that the benefits are coded as per the Client Intent. Perform the impact analysis on the defects identified and make sure that process is updated across the TCOE to improve the quality of deliverables. Perform GAP Analysis on different lines of business by ensuring the requirement traceability with the test cases and ensure every requirement mentioned in the CRD will have positive and negative scenarios in the testbed (test Scenarios) and ensure all pharmacy networks are covered.
Required QualificationsA Master’s degree or foreign equivalent in Business Administration, Engineering, Computer Science, Information Systems, IT, Technology, or closely related technical field and 2 years of experience with PBM plans to include Medicare, or Medicaid, or Commercial, or HMO; setup or testing of PBM; RxClaim application; Project Management; MS Project; and SQL required. In lieu of Master’s degree and 2 years of experience, will accept a Bachelor’s degree and 5 years. 0-5% of domestic travel required. Must apply by 06/01/18.
Preferred QualificationsPlease see required qualifications.
EducationA Master’s degree or foreign equivalent in Business Administration, Engineering, Computer Science, Information Systems, IT, Technology, or closely related technical field and 2 years of experience with PBM plans to include Medicare, or Medicaid, or Commercial, or HMO. In lieu of Master’s degree and 2 years of experience, will accept a Bachelor’s Degree and 5 years of experience.
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
and EEO IS THE LAW SUPPLEMENT
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. If you require assistance to apply for this job, please contact us by clicking EEO AA CVS Health
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/