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.

Brief Overview

• Facilitates the successful implementation of Medicaid health plan operations programs by coordinating with cross-functional teams. Enhances operational efficiency, ensures compliance with regulatory standards, and contributes to the overall success of healthcare operations. Assists in the management of stakeholder relationships and establishes communication channels to promptly address concerns regarding claims payment, contract or benefit setup.
  

Job Summary

• Collect, analyze, and interpret operational data to identify trends, patterns, and insights that inform decision-making and drive improvements in operations.
• Analyze operational issues, incidents, and provider complaints and identify root causes, propose solutions, and collaborate with relevant teams to implement corrective actions, claims payment reconfiguration and prevent recurrence.
• Apply knowledge of medical coding and billing to ensure accurate and efficient claims processing.
• Review and analyze complex claim documentation, assess policy coverage and claim validity, collaborate with internal and external stakeholders, and contribute to process improvement initiatives.
• Identify potential risks and issues that could impact health plan operations success and develop mitigation plans to address them proactively.
• Ensure that program deliverables meet quality standards and comply with relevant healthcare regulations and best practices.
• Implement change management strategies to address resistance and ensure smooth transitions during program implementation.
  
  

Required Experience

• 5+ years in healthcare operations
• 3+ years reviewing medical claims
• Knowledge of provider reimbursement methodologies

Preferred Experience

• QNXT claims experience
• Claims editing
• Knowledge of healthcare billing standards and code sets

Education

• Bachelor's degree preferred/specialized training/relevant professional qualification.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,300.00 - $119,340.00

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.

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.

Great benefits for great people

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.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 02/14/2026

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