Sr. Manager, Pricing - Pharmacy Appeals

Overview

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

The Senior Manager, Pricing will lead a team of colleagues and contractors in the management of specific functions related to pharmacy reimbursement appeals, including the Service Warranty process, as well as supporting the Department of Insurance and Secondary Appeals operations. You will ensure appeals are executed under tight Turnaround Times (TATs) and with high accuracy, while ensuring the team is appropriately staffed and organized.

You will develop and implement solutions, individually and with partners, to improve and automate processes to increase productivity and fulfill state regulatory changes. You will lead and coach the appeal team coordinators and guide other internal business units to resolve issues quickly. You will also work with the legal and compliance teams to ensure state regulatory updates are operationalized. This role requires thorough knowledge of claim adjudication, appeals-related processes, and leadership across internal business units to develop new solutions for increasingly complex appeal bill compliance requirements.

The position will be responsible for quality control to ensure compliance.

• Lead with strategic leadership and guidance to pharmacy reimbursement appeals teams, ensuring effective strategies and operations are progressed to improve performance.
• Oversee the pharmacy appeals service warranty process to ensure timely processing and compliance with state regulations.
• Review and respond to complex inquiries related to pharmacy reimbursement appeals submitted by state regulators and pharmacies.
• Analyze market trends and competitive insights to generate actionable recommendations.
• Collaborate cross-functionally with legal, finance, and account teams to align client strategies with business goals, enhance value propositions, and optimize appeals services.
• Influence stakeholders through effective communication and negotiation, leveraging operations expertise and industry knowledge to establish mutually beneficial partnerships and agreements.
• Apply experience-based pharmacy claims and appeals knowledge to influence strategic decision-making.
• Counsel and mentor team members, providing guidance and support to enhance their skills and professional development.

• 7 years’ experience in pricing, PBM/healthcare operations, process improvement, quality, analytics, or related domains
• 5+ years directly leading operations teams
• 1+ years’ experience with pharmacy appeal-related processes and state regulations, and claims adjudication, including claims adjudication logic

• Excellent leadership skills
• Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal
• Ability to work under tight deadlines
• Strong mathematical problem-solving skills
• Prior PBM knowledge
• Familiarity with wholesaler invoices

Bachelor’s Degree or equivalent experience required.

The typical pay range for this role is: $67,900.00 - $

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. We offer a comprehensive and competitive mix of pay and benefits designed to support the physical, emotional, and financial well-being of colleagues and their families, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and in Benefits Moments.

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

This full‑time position is eligible for a comprehensive benefits package and compensation plan as described above.