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Position Summary

As a Manager, Medical Economics, Medical Expense Review, you will define, develop and provide information and analysis to drive the decision making process for internal leadership related to Medical Economics - Medical Expense Review (MER) across assigned Medicaid Plans. The primary goal of this team is to provide accurate, relevant data and analysis for utilization and unit cost management to support each Plan in controlling medical costs and driving a targeted financial strategy.

• Align with senior Local Plan and Medical Economics leaders to monitor performance to Medical Cost Savings Targets, as well ensure analytics are supporting Plan strategy and financial targets.

• Present recommendations to management based on analysis.

• Manage the consistent production and analysis of medical cost trend results used to formulate effective network contracting and utilization management strategies.

• Work with Operations to ensure payment accuracy and recovery projects based on specific claims outlier and trend findings.

• Manage a team of Senior Consultants/Consultants to ensure medical cost opportunities are being identified for the assigned Plans.

Required Qualifications

Knowledge of:

• Knowledge of the healthcare industry and analytics

• Understanding of internal and external database applications.

• Familiarity with managed care functions including provider contracting, benefit design, medical management, knowledge of business functions and impact on financials (underwriting, sales, product development, network management)

Skill In:

• Advanced communication/presentation skills.

• Healthcare analysis

• Managed care contracting

• Working with large datasets

Ability To:

• Lead team members in proactive analysis/research around utilization and unit cost medical costs drivers for the assigned Medicaid Plans.

• Lead and manage a team of colleagues with diverse skills to work collaboratively across departments in a highly matrixed organization to communicate potential opportunities to mitigate trend divers

• Ideate and utilize analytical models to determine the savings opportunities to mitigate medical cost drivers. Working across Plan leaders to understand their savings initiatives to determine if initiatives can be shared across other Plans

• Lead discussions and presentations with the Plan leadership and National leadership about medical cost drivers and mitigating cost opportunities. Facilitate/host discussions to discuss the medical cost drivers with Plan leadership to act on the drivers: Plan CEO, Plan CFO, Market Clinical Leads, Actuarial, Chief Network Officer, Operations

• Work in a matrixed cross-functional organization to help achieve operational targets

• Perform complex functions in Excel, MS-Access, and Web-based query tools (MCM, data warehouse).

• Demonstrate innovation and leadership in achieving results

• Demonstrates critical thinking and expresses ideas clearly, concisely and logically from a cross functional perspective.

• Ability to manage conflicting priorities and multiple projects concurrently

• Develops standards and best practices for MER team.

Preferred Qualifications

Knowledge of:

• Advanced analytical tools – SAS, SAS Enterprise Guide experience

• Contract payment terms and relationship to claims payment

Skill in:

• Strong analytical ability and familiarity with advanced financial and healthcare concepts

• Advanced college degree at the Masters level

Ability To:

• Develop analytical tools and models

Education

Bachelors degree required

5-8 years of relevant work experience related to healthcare claims analytics or financial analysis and data modeling.

Role is in office Tuesday - Thursday if candidate is located near hub location

Pay Range

The typical pay range for this role is:

$75,400.00 - $182,549.40

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 10/28/2024

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

We are an equal opportunity and affirmative action employer. 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.