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

Oversees and optimizes the day-to-day Medicaid service operational functions of our organization by providing strategic direction, leading cross-functional teams, and ensuring efficient and effective operations across multiple departments including but not limited to System Configuration, Claims, Encounters, Appeals & Grievances, Member Services, Provider Call Center, Network Mgt, Provider Experience, and Provider Data Services.

Required Qualifications

10-15 years work experience.

Proficient in Healthcare Service Operations including Lifecyle of a claim, adjudication system configuration, and provider data records.

Experience in Medicaid Federal government Managed Care Organization contract operations compliance.

Oversees and optimizes the operational functions of our organization by providing strategic direction, leading cross-functional teams, and ensuring efficient and effective operations across multiple departments.

Develops and implements operational strategies aligned with the organization's goals and objectives.

Leads the development and execution of annual operating plans, budgets, and key performance indicators (KPIs) for various departments.

Develops processes for operational improvement to optimize processes, reduce costs, and increase efficiency.

Communicates cross-functional initiatives to drive process improvements, streamline workflows, and enhance operational effectiveness.

Delivers action plans to address performance gaps and ensure operational goals are met.

Communicates with top management to understand their needs and expectations and ensure operational processes align with their requirements.

Controls internal controls and processes to safeguard company assets and ensure operational integrity.

Counsels crisis management efforts and develops contingency plans to minimize operational disruptions.

Develops and implements talent management strategies, including recruitment, training, and performance management. Benchmarks key performance indicators for projects, operations, and teams. Manages operational aspects of the team (e.g., budget, performance, and compliance), and implements workforce and succession plans to meet business needs.

Adept at collaboration and teamwork. 

Preferred Qualifications

Advanced knowledge of medical coding and billing practices to play a crucial role in ensuring accurate and efficient claims processing while maintaining compliance with industry regulations and standards. Reviews and analyzes complex claim documentation, assesses policy coverage and claim validity, provides guidance and support to junior team members, collaborates with internal and external stakeholders, and contributes to process improvement initiatives.

Identify and facilitate resolutions to configuration, processing, and billing issues.

Experience with query tools; Documents analytic reports for clients and stakeholders.

Project Management skills.

Microsoft Suite

Education

Bachelor's degree or equivalent work experience

Master's degree preferred

Pay Range

The typical pay range for this role is:

$100,000.00 - $231,540.00

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 people

We 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 07/25/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.