CVS Health Careers

Credentialing Specialist

• Review and process credentialing and re-credentialing files
• Establish and maintain a system for timely processing of credentialing files in accordance with NCQA policies
• Query appropriate organizations and evaluate responses to ensure provider compliance with NCQA standards
• Maintain current state licenses, DEA certificates, malpractice coverage, and other required credentialing documents for providers
• Review background checks, drug tests, and TB screenings and record results
• Assemble verified information and prepare files for Credentialing Committee presentation
• Verify providers’ requirements for approval to work in specific states and health plans
• Assist with ongoing monitoring of contracted clinicians
• Use the MD Staff credentialing database to perform queries, generate reports, and optimize efficiency
• Provide administrative support to department leadership and internal and external stakeholders
• Provide timely, professional email responses
• Demonstrate teamwork and assist with special projects
• Protect the security and privacy of protected health information (PHI)
• Report to the Credentialing Supervisor

Explore Credentialing Specialist at CVS Health Careers. Review requirements and application details.

Medical Director

• Review clinical cases and coverage requests, including specialty medications, oncology therapies, biologics, and newly marketed drugs
• Identify, evaluate, and apply current medical literature and evidence-based guidelines
• Synthesize complex clinical information and assess the strength of available evidence
• Make objective, well-supported coverage determinations
• Provide clinical support and consultative activities across the PBM
• Provide consultative clinical support to Account Management for assigned key clients
• Complete assigned medication utilization reviews and/or medical necessity appeals for commercial, Medicare, Medicaid, and individual clients
• Participate in peer-to-peer conversations when required
• Support other business segments during evening and weekend coverage when assigned to one segment
• Participate in inter-rater review activities and quality oversight processes
• Provide oversight of portions of CVS Health’s clinical programs and commercial client program support
• Share in reviews of utilization management criteria and clinical policy revisions
• Perform special clinical investigations and research
• Review pharmaceutical literature and collaborate with pharmacists within Medical Affairs and other business units
• Participate as a clinical decision-making and professional thought partner across enterprise decisions and planning

Explore Medical Director, Medical Affairs at CVS Health Careers. Review requirements and application details.

Medical Director, Medical Affairs

• Lead a team of approximately 7–8 Clinical Program Consultants
• Provide day-to-day oversight of customer-facing CPC work
• Set priorities and align resources with Field partners' and customers' needs
• Collaborate with Field leaders to support business retention and growth objectives
• Provide coaching and development to team members
• Work directly with customers in a strategic advisory role as needed
• Collaborate with Aetna National Accounts Field Sales and Service staff to identify customers who may benefit from clinical management programs
• Evaluate and analyze medical, pharmacy, behavioral health, and disability trend drivers
• Propose clinical programs and improvements to manage trends and optimize return on investment
• Consult with clients on employee health trends and tailor cost-management strategies
• Maximize clinical and financial outcomes for customers
• Identify and help rectify clinical program gaps
• Manage changing projects and priorities and mitigate negative outcomes
• Serve as a key resource on clinical programs for Aetna National Accounts
• Evaluate performance through regular, timely feedback to support service delivery, engagement, motivation, and team development

Explore National Accounts Lead Director, Clinical Program Consultant at CVS Health Careers. Review requirements and application details.

National Accounts Lead Director, Clinical Program Consultant

Associate

• Support comprehensive coordination of medical services, including intake, screening, and referrals to Aetna Better Health
• Promote and support quality effectiveness of Healthcare Services
• Perform intake of calls from members or providers regarding services via telephone, fax, and EDI
• Use Aetna systems to build, research, and enter member information
• Screen requests for appropriate referral from medical services staff
• Approve services that do not require medical review in accordance with the benefit plan
• Perform non-medical research, including eligibility, COB, and benefits verification
• Maintain accurate and complete documentation meeting risk management, regulatory, and accreditation requirements
• Promote internal and external communication with claim administrators, Plan Sponsors, third-party payers, members, families, and healthcare team members
• Communicate with Aetna Case Managers, Nurses, and Medical Directors when processing member transactions
• Support administration of the precertification process in compliance with applicable laws, regulations, NCQA standards, and company policies
• Place outbound calls to providers to provide information or obtain clinical information for medical authorization approval
• Work scheduled hours between 8am and 6pm EST, Monday through Friday

Explore Inbound/Outbound Queue Associate at CVS Health Careers. Review requirements and application details.

Inbound/Outbound Queue Associate

• Provide clinical support and consultative activities across the PBM
• Provide consultative clinical support to Account Management for assigned key clients
• Review medication utilization requests and medical necessity appeals for commercial clients, Medicare/Medicaid programs, and individual client coverage determinations
• Participate in peer-to-peer conversations when required
• Support evening and weekend coverage across commercial, Medicare, and Medicaid segments as needed
• Participate in inter-rater review activities and quality oversight processes for internal Director utilization-management decisions
• Provide oversight of portions of CVS Health’s clinical programs and commercial client program support
• Share in reviews of utilization management criteria and clinical policy revisions and reviews
• Perform special clinical investigations and research requested by the Senior Medical Director
• Review published literature on pharmaceutical questions and collaborate with pharmacists within Medical Affairs and other business units
• Review clinical cases and coverage requests involving specialty medications, oncology therapies, biologics, and newly marketed drugs
• Synthesize clinical information, evaluate medical evidence, and make objective, evidence-based coverage determinations

• Support comprehensive coordination of medical services, including intake, screening, and referrals
• Promote and support quality effectiveness of Healthcare Services
• Perform intake of calls from members or providers regarding services via telephone, fax, and EDI
• Utilize Aetna systems to build, research, and enter member information
• Screen requests for appropriate referral from medical services staff
• Approve services that do not require medical review in accordance with the benefit plan
• Perform non-medical research including eligibility, COB, and benefits verification
• Maintain accurate and complete documentation meeting risk management, regulatory, and accreditation requirements
• Promote internal and external communication with claim administrators, Plan Sponsors, third-party payers, members, families, and healthcare team members
• Protect confidentiality of member information and adhere to company confidentiality policies
• Communicate with Aetna Case Managers, Nurses, and Medical Directors when processing member transactions
• Support administration of the precertification process in compliance with laws, regulations, NCQA standards, and company policies
• Place outbound calls to providers to provide information or obtain clinical information for approval of medical authorizations
• Use Aetna systems such as MedCompass, QNXT, ProFAX, and ProPAT

Customer Success Manager

• Set engagement strategy and priorities across the client portfolio
• Sequence engagements and meetings to advance relationships toward milestones
• Lead planning and preparation of client engagements with the AVP of Customer Success
• Define engagement objectives and approaches
• Confirm internal stakeholders and subject matter experts and key messages
• Support discovery and pre-sales conversations with prospective clients
• Prepare leadership for client interactions with client context, relationship history, and objectives
• Capture outcomes, meeting notes, action items, owners, and next steps
• Ensure timely follow-up with clients and internal stakeholders
• Maintain a consolidated view of engagement activity across all clients
• Produce regular reporting for Customer Success leadership
• Adapt engagement plans as client needs and priorities evolve

Explore Lead Director – Strategic Customer Engagement Operations at CVS Health Careers. Review requirements and application details.

Lead Director – Strategic Customer Engagement Operations

Quality Specialist

• Act as a quality champion and subject matter expert for claim processing and customer service processes
• Measure and monitor quality and effectiveness of work processes impacting customer satisfaction, medical cost management, and operational efficiency
• Consult cross-functionally to influence and promote change and deliver quality service to internal and external customers
• Perform regular quality audits for service operations across multiple products and platforms
• Execute routine and non-routine business support tasks under limited supervision
• Follow area protocols, standards, and policies
• Support Quality Specialist workflows, policies, system requirements, enhancements, daily operations, and programs
• Conduct quality reviews and audits to monitor compliance with published policies and procedures
• Support targeted quality audit projects, report results, and recommend training needs, quality controls, and procedures to senior management
• Execute assigned techniques, processes, and responsibilities

Explore Senior Quality Specialist at CVS Health Careers. Review requirements and application details.

Senior Quality Specialist

Consultant

• Review clinical information and apply evidence-based criteria to make coverage recommendations
• Collaborate with providers and interdisciplinary teams to support care coordination
• Identify opportunities to improve quality, outcomes, and healthcare resource utilization
• Refer members to appropriate programs and services supporting their healthcare needs
• Serve as a clinical resource for internal and external stakeholders
• Support the 24/7 Utilization Management team
• Assess medical necessity and coordinate care
• Use clinical judgment to optimize healthcare outcomes

Explore Utilization Management Nurse Consultant at CVS Health Careers. Review requirements and application details.

Utilization Management Nurse Consultant

Manager

• Lead environmental, health, safety, and regulatory compliance programs across pharmacy, repackaging, distribution, and corporate operations
• Serve as a subject matter expert for environmental compliance, hazardous and pharmaceutical waste management, occupational safety, emergency preparedness, and regulatory reporting
• Ensure compliance with OSHA, EPA, DOT, and applicable state and local regulations
• Monitor regulatory changes and assess impacts to operations
• Support regulatory inspections, audits, and compliance assessments
• Manage environmental permits, licenses, registrations, and reporting requirements
• Oversee hazardous waste, pharmaceutical waste, controlled substance waste, regulated medical waste, and sharps management programs
• Coordinate waste vendor activities, manifests, exception reporting, and compliance documentation
• Manage environmental compliance programs including spill prevention, contingency planning, emergency response, and environmental reporting
• Support EPCRA Tier II, hazardous materials, and environmental permit compliance activities
• Develop and implement environmental sustainability and waste-reduction initiatives
• Conduct facility inspections, safety audits, hazard assessments, and compliance evaluations
• Lead incident, injury, near miss, spill, and environmental release investigations
• Perform root cause analyses and ensure timely completion of corrective and preventive actions (CAPAs)
• Track and trend EHS performance metrics and communicate findings to leadership
• Develop and deliver EHS training programs
• Ensure completion and documentation of required compliance training
• Provide guidance and technical support to operations, facilities, and leadership teams
• Promote a proactive safety culture through communication, coaching, and employee engagement initiatives
• Maintain emergency response, spill response, and business continuity programs
• Coordinate preparedness activities for severe weather, environmental incidents, and other emergencies
• Serve as an EHS resource during emergency events and regulatory reporting activities
• Partner with site leadership and operational teams to foster safety, environmental stewardship, and continuous improvement

Explore Associate Manager – Environmental, Health and Safety at CVS Health Careers. Review requirements and application details.

Associate Manager – Environmental, Health and Safety

Account Executive

• Own the relationship with the broker
• Build and maintain broker relationships for an exceptional client experience
• Communicate and demonstrate Meritain's total cost of care through simplicity, transparency, and versatility
• Manage relationships and provide consultative services
• Prepare and issue renewal proposals
• Confirm sold proposals and plan changes
• Ensure clients are up to date with compliance requirements
• Manage Salesforce
• Conduct virtual open enrollment meetings
• Attend implementation calls
• Prepare Stop Loss and ad-hoc reporting
• Upsell point solutions
• May travel to offsite locations for in-person meetings

Explore Account Executive – Meritain Health at CVS Health Careers. Review requirements and application details.

Account Executive – Meritain Health

Nurse

• Coordinate and facilitate comprehensive care for individuals by assessing needs, developing personalized care plans, and coordinating services across healthcare providers
• Advocate for patients and ensure effective communication, resource utilization, and continuous progress monitoring
• Act as liaison among members/clients/families, employers, providers, insurance companies, and healthcare personnel
• Coordinate case management activities for catastrophic cases and chronically ill members/clients across the continuum of care
• Coordinate consultant referrals, home care visits, community resources, and alternative levels of care
• Interact with members/clients telephonically or in person, including at homes, worksites, or physician offices
• Assess and analyze medical and/or vocational status
• Develop plans of care to optimize wellness and medical outcomes, support timely return to work, and determine benefit eligibility
• Communicate with members/clients and stakeholders including medical providers, attorneys, employers, and insurance carriers
• Prepare required case work documentation
• Consult with internal multidisciplinary teams
• Contact treating physicians or specialists regarding course of care and treatment
• Provide education and prevention information
• Apply applicable rehabilitation-service laws, regulations, insurer instructions, and referral-source requirements
• Evaluate member/client needs and benefit plan eligibility using clinical tools and data
• Apply case management processes in compliance with regulatory and company policies
• Develop proactive actions to improve short- and long-term outcomes and overall wellness
• Monitor progress toward desired outcomes through assessment and evaluation

Explore Case Manager, Registered Nurse at CVS Health Careers. Review requirements and application details.

Case Manager, Registered Nurse

• Coordinate and facilitate comprehensive care for individuals by assessing needs, developing personalized care plans, and coordinating services across healthcare providers
• Advocate for patients and ensure effective communication, resource utilization, and continuous progress monitoring
• Act as liaison among members/clients/families, employers, providers, insurers, and healthcare personnel
• Coordinate case management activities for catastrophic cases and chronically ill members across the continuum of care
• Conduct consultant referrals, home care visits, community resource coordination, and alternative-level-of-care arrangements
• Interact with members/clients telephonically or in person, including at homes, worksites, or physician offices
• Assess medical and/or vocational status and develop plans of care
• Support condition management, wellness, medical outcomes, timely return to work, and optimal functioning
• Communicate with members/clients and stakeholders including medical providers, attorneys, employers, and insurance carriers
• Prepare required case work documentation
• Consult with internal multidisciplinary teams
• Contact treating physicians or specialists regarding care and treatment
• Provide education and prevention information
• Apply laws, regulations, insurer instructions, and referral-source requirements
• Evaluate needs and benefit-plan eligibility using clinical tools and data
• Monitor progress toward desired outcomes through assessment and evaluation
• Develop proactive action plans to improve short- and long-term outcomes

Business Analyst

• Serve as a Scrum Team member on the Medicare / Medicaid / Exchange Enrollment Configuration team
• Develop purpose-built capabilities for the NextGen platform
• Deliver analysis and requirements oversight for Membership Integration and Reconciliation stories within an Agile framework
• Own detailed data and process analytics, process improvements, process flow creation, requirements gathering, and requirements traceability through the software delivery lifecycle
• Contribute to estimation, resource planning, capacity planning, testing framework and strategy, and post-implementation review

Explore Pharmacy Eligibility/Claims Business Analyst at CVS Health Careers. Review requirements and application details.

Pharmacy Eligibility/Claims Business Analyst

Data Analyst

• Support applications critical to pricing operations and underwriting transformation
• Design, develop, and enhance foundational data forecasting tools for PBM pricing and underwriting
• Translate business processes and requirements into analytical requirements for technical partners
• Execute user acceptance testing and support quality assurance efforts
• Perform data integrity checks using Google Cloud Platform, Databricks, Excel, Salesforce reporting, and Tableau
• Assist with live pricing support and ad-hoc analysis
• Identify trend shifts and key data changes used to underwrite client deals
• Collaborate with product owners, business owners, IT partners, and leadership to execute the product vision
• Support end users, business teams, and development teams through issue resolution, communication, and training
• Translate business needs into analytical requirements using JIRA
• Guide users to existing tools and insights and identify opportunities for new solutions
• Design controls and standard operating procedures to improve efficiency and governance

Explore Senior Underwriting Analytics Analyst at CVS Health Careers. Review requirements and application details.

Open roles

Credentialing Specialist

Medical Director, Medical Affairs

National Accounts Lead Director, Clinical Program Consultant

Inbound/Outbound Queue Associate

Medical Director, Medical Affairs

Inbound/Outbound Queue Associate

Lead Director – Strategic Customer Engagement Operations

Senior Quality Specialist

Utilization Management Nurse Consultant

Associate Manager – Environmental, Health and Safety

Account Executive – Meritain Health

Case Manager, Registered Nurse

Case Manager, Registered Nurse

Pharmacy Eligibility/Claims Business Analyst

Senior Underwriting Analytics Analyst