Network Management - Analyst
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 is an exciting opportunity to join a specialized team of auditors as part of CVS Caremark's extensive Pharmacy Audit division. The Medicare Pharmacy Claims Auditor will administer assigned Medicare Part-D Compliance Audit Programs, review pharmacy submitted Medicare claims, make independent decisions, and call network pharmacies to audit submitted information and communicate business requirements. Candidates will work with other auditors to successfully complete audit projects. Candidates must be highly motivated, possess strong communication skills, effective time-management skills, and be very detail-oriented. Candidates will become an expert on the CVS Health Medicare Audit Programs and will own one or more of those program processes on an ongoing basis. Candidates must possess extremely strong teamwork and collaboration skills and be skilled in sharing common workloads with peers. Candidates will have expansive opportunities to innovate and develop new tools to enhance the execution of audit programs, and work with internal and external partners to develop successful solutions within the scope of the processes for which they are accountable. This helps keep CVS Health plans in compliance with CMS requirements and maintain positive STAR ratings.Daily Tasks may include:
-Telephone outreaches to network pharmacies to verify claim information.
-Transmission of audit requests to pharmacies.
-Review of hard copy prescriptions to verify compliance with CMS requirements and CVS Health contractual requirements.
-Review incoming documentation from pharmacies and input information into internal CVS Health audit systems.
-Corresponding with network pharmacies to answer questions regarding Medicare Audit Programs.
-Monitor assigned audit processes and report statuses on a regular basis.
-Meeting with internal partners to develop and communicate business objectives.Required Qualifications
-1+ year(s) combined experience in a PBM or pharmacy.
Preferred Qualifications
-5+ years combined experience in PBM or pharmacy.
-2+ years experience in PBM or pharmacy claim processing systems.
-Familiarity with current CMS Medicare Part-D compliance regulations.
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-Advanced level of technical skillsets including Microsoft Excel, Microsoft Access, and SQL databases.
-PTCB certification.
Education
Verifiable High School Diploma or GED required. Bachelor's Degree preferred. Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:$43,888.00 - $85,068.00This 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:
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- 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.
Perks and Benefits
Health and Wellness
- Health Insurance
- Dental Insurance
- Vision Insurance
- Life Insurance
- HSA
- HSA With Employer Contribution
- Pet Insurance
- Mental Health Benefits
Parental Benefits
- Fertility Benefits
- Adoption Assistance Program
- Family Support Resources
Work Flexibility
- Flexible Work Hours
- Remote Work Opportunities
- Hybrid Work Opportunities
Office Life and Perks
Vacation and Time Off
- Paid Vacation
- Paid Holidays
- Personal/Sick Days
Financial and Retirement
- 401(K) With Company Matching
Professional Development
- Tuition Reimbursement
Diversity and Inclusion
- Employee Resource Groups (ERG)
- Diversity, Equity, and Inclusion Program