Lead Director, Pharmacy Appeals

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.

The Lead Director, Pharmacy Appeals will lead a team of 40+ colleagues in the management of pharmacy reimbursement appeals, both generic (MAC) and brand (Non-MAC). In this role, you will ensure the appeals are executed under tight Turnaround Times (TATs) and with high accuracy while making sure the team is appropriately staffed and organized. In addition, you will be responsible for developing and implementing solutions and being a lead working with partners to improve and automate processes to increase productivity and fulfill state regulatory changes.

You will be leading and coaching the appeal team as well as guiding other internal business units to resolve issues quickly. The Lead Director, Pharmacy Appeals is also responsible for working with the Presidential Response Unit (PRU) to resolve pharmacy appeals submitted directly by state agencies and with the legal and compliance team to ensure state regulatory updates are operationalized.

This role requires a thorough knowledge of claim adjudication, internal MAC & non-MAC related processes, and being a leader working with other internal business units to develop new solutions to meet the ever-increasing number of complex appeal bill compliance requirements. The position will be responsible for quality control process to ensure compliance.

• Establish processes (with SOPs), capacity / forecast planning, and tools to execute operational service catalog
• Implement key performance indicators (KPIs) to manage operations
• Maintain effective working relationships with a variety of internal and external partners, including PRU, legal, compliance, regulatory, data science, and information technology.
• Execute process improvements and system enhancements, including coordinating activates across diverse departments and ensure that contributions across different teams are lined and integrated as part of overall delivery
• Oversee and lead operational teams in finance function
• Improve internal processes to demonstrate accuracy and transparency in financial management
• Counsel and mentor team members, provide guidance and support to enhance their skills and professional development.

• 10 year's experience in healthcare industry with experience in price management, optimization or modeling.
• 5+ years directly leading operations teams
• 1+ years' experience with pharmacy appeal related processes and state regulations, and claims adjudication, including claims adjudication logic

• Outstanding written and oral communication skills, including developing and presenting strategic plans and presentations to executive and technical audiences with the goal of obtaining feedback and alignment on project goals and delivery strategies
• Requires exceptional judgment, discretion and confidentiality
• 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:
$ - $
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…