Manager, Clinical Adjudication Prior Authorization Solutions

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 Clinical Adjudication Prior Authorization Support (CAPAS) Team delivers end-to-end support for Member Prior Authorization (PA) override services, working in close partnership with internal stakeholders and external clients. As subject matter experts in PA override functionality, CAPAS drives enterprise-wide initiatives and ensures operational excellence - particularly in the configuration and management of override records within the RxClaim platform. As the Manager, Clinical Adjudication PA Solutions, you will lead efforts to support PA processes across the enterprise, applying deep expertise in PA configuration, consulting, training, and coaching.

You will oversee a broad spectrum of PA requests, ensuring timely, accurate, and compliant support for business operations.

• Conducting research in Rx Claim
• Documenting business requirements for IT initiatives
• Consulting on clinical testing efforts
• Identifying root causes of adjudication issues
• Supporting leadership activities and escalating risks as needed

In this role, you will maintain PA records in RxClaim, upload and update authorizations, research member configurations, run PA Queries to extract configuration data, generate reports, and contribute to process improvement and automation initiatives.

You are expected to follow established procedures, meet service level agreements (SLAs), and uphold a zero-defect service standard while managing daily workflows. A proactive, innovative, and collaborative mindset is essential - especially when engaging in cross-functional projects and enterprise initiatives.

Finally, you are expected to embody CVS Health's Heart at Work behaviors, fostering a culture of compassion, accountability, and collaboration that positively impacts the health and well-being of our customers and communities.

• Lead and close deliverables related to department initiatives and PA activities in a timely manner
• Support CAPAS service catalog offerings
• Maintain CAPAS service-related job aids and documentation
• Drive innovative improvements across CAPAS operations
• Validate functionality of new programs and innovations
• Support implementation of client PA files during the clinical review portion of member data transitions
• Assist partners in understanding adjudication claim processing
• Provide training and cross-training to internal CAPAS team members, including new hires and advanced deep-dive sessions

• Strong problem-solving and decision-making skills
• Proven ability to collaborate effectively across teams
• Demonstrated growth mindset, with agility in learning and developing self and others
• Strong execution and delivery skills, including planning, implementation, and support
• Self-motivated with a positive, proactive attitude
• Excellent communication and organizational skills, with the ability to clearly articulate complex technical concepts to non-technical audiences

• Minimum 5 years of experience with RxClaim, specifically in adjudication related to Prior Authorization overrides
• Experience running queries in RxClaim and/or Data Warehouses
• Advanced proficiency in Microsoft Office Suite, particularly Excel, Access, and Visio

• Knowledge of CVS Caremark clinical programs (e.g., Benefit plan setup, formularies, utilization management)
• Experience developing or enhancing training materials
• Familiarity with Microsoft Power Platform

• Bachelor's degree required; equivalent work experience may substitute

Anticipated Weekly

Hours:

40

Time Type:
Full time

The typical pay range for this role is:

$60,300.00 - $

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.

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
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• No-cost programs for all colleagues including wellness screenings,…