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CVS Health Advisor, Clinical Adjudication PA Support in Irving, Texas

Job Description

As the Clinical Adjudication PA Support Advisor, you will support Prior Authorization (PA) subject matter focused on formulary and utilization management adjudication. You will assist researching in RxClaim, participate in or lead business requirement determinations and documentation for IT projects and will consult on clinical testing initiatives and collaborate to identify root cause of override issues. You will need to be innovative and collaborative and will be involved in various projects or initiatives related to PAs. You may be required to present initiative or project updates to leadership and call out risks and issues as appropriate. Additional responsibilities include:• Leading and closing deliverables resulting from department initiatives and PA activities in a timely manner• Supporting CAPAS service catalog offerings• Incorporating innovative improvements into all aspects of the CAPAS operations• Validating functionality of new programs and innovations• Supporting implementation of client PA files during the Clinical review portion of the member data transition process• Assisting our partners to become knowledgeable on adjudication claim processingYour success will be determined by your ability to inspire change and drive alignment in a matrixed environment by demonstrating CVS Health core values including collaboration and accountability. The ability to think strategically, apply proven reasoning and logic for CAPAS related projects and initiatives and articulate risks or concerns is vital for success in this role.This is a work from home role. Candidates can live anywhere in the US.

Required Qualifications

• 5+ years of analytical skills working with large data sets for initiatives or trending/opportunity identification• 3+ RxClaim experience (specifically adjudication related to PA overrides)

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.

  • If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

  • If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications

• Advanced proficiency in Microsoft Office Suite• Ability to run queries in RxClaim or Data Warehouses• Must be self-motivated with a strong, positive attitude • Superb communication and organizational skills – must be able to articulate complex/technical concepts to non-technical/lay users• Knowledge of CVS Caremark clinical programs• Experience in developing or improving training materials • Experience using MS Access databases


• Bachelor's degree is required• Equivalent work experience may substitute

Business Overview

At CVS Health, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.