CVS Health

Consultant

• Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for Behavioral Health, specific to ABA.
• Utilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, applying evidence-based standards and practice guidelines to treatment where appropriate.
• Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage.
• Coordinates with providers and other parties to facilitate optimal care/treatment.
• Identifies members at risk for poor outcomes and facilitates referral opportunities to integrate with other products, services and/or programs.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

ABA UM Clinical Consultant

Product Manager

• Partner with multiple Product Owners and Product leadership team right from the ideation phase to mature the product concepts and helps them with IT evaluation exercise (SWAT)
• Work with multiple IT and business areas to develop IT solution, strategy, MVP (Minimum Viable Product and provides the IT Guidance ranges/cost estimates
• Coordinate release planning, oversees delivery milestones, resolves issues, and removes the barriers that may hinder project execution
• Proactively evaluates all work that is in flight, builds contingency plans, and executes corrective action on a timely basis to mitigate risks such as scope and/or budget variances
• Ensure that projects/enhancements align with the Commercial Product delivery objectives by thoroughly understanding the business segment's drivers and issues
• Identify and leverage project interdependencies to ensure synergy between the projects and to promote benefits realization across the portfolio.

Senior Manager – Digital Product Manager

Pharmacist

• Processes prior authorization requests received by phone, fax, or electronically
• Completes prior authorization approvals and denials
• Follows prior authorization workflow, policies, and procedures
• Answers inquiry calls from providers and pharmacies
• Participates in training and continuing education

Pharmacy Technician – Prior Authorization

Architect

• connect business needs with technical execution
• engage closely with business stakeholders to clarify and refine requirements
• translate high-level concepts into actionable roadmaps and user stories
• ensure alignment across cross-functional teams
• develop high-level and detailed solution designs
• document current-state architectures
• propose scalable, secure improvements for future-state systems
• primarily work within Google Cloud Platform (GCP)
• support the integration and modernization of internal applications
• create and maintain architecture roadmaps
• estimate development efforts
• ensure solutions are strategically aligned with business goals

Lead Architect

Account Executive

• responsible for selling CVS/specialty pharmacy services to key targeted physicians, medical clinics, hospitals, and academic institutions
• support the Oncology, IVIG, Pulmonary Hypertension / IPF, Autoimmune, and be the primary contact for respective providers within the assigned territory
• work independently to formulate and execute effective marketing plans in the designated territory
• measure success through percent to sales goal metrics, internal and external client satisfaction and success of aligned Inside Sales Representative(s)

Territory Sales Executive – Pharmacy Services

Events

• Assists with establishing and implementing results-based programs for the Prevention & Wellness area
• Applies in-depth knowledge of the Prevention & Wellness field to offer feedback and innovation strategies
• Develops, implements, and assures ongoing coordination of prevention and wellness activities
• Evaluates, analyzes, reports on, and records outcomes of scheduled interventions

Senior Outreach Coordinator, Prevention & Wellness – Bilingual Spanish

Manager

• Negotiates, executes, conducts high level review and analysis of dispute resolution and/or settlement negotiations of contracts with national providers
• Recruit providers as needed to ensure attainment of network expansion goals
• Support health plan with expansion initiatives or other contracting activities as needed
• Initiates, coordinates and own the contracting activities to fulfillment
• Responsible for auditing, building, and loading contracts, agreements, amendments and/or fee schedules in contract management systems per Aetna ’ s established policies
• Conducts research, analysis and/or audits to identify issues and propose solutions
• Manages contract performance and supports the development and implementation of value-based contract relationships
• Collaborates cross-functionally to manage provider compensation and pricing development activities
• Provides Subject Matter Expert support for questions related to recruitment initiatives, contracting, provider issues/resolutions, related systems and information contained
• Provide guidance and share expertise to others on the team
• Understanding of Value Based contracting and negotiations
• Manage high level projects and recruitment initiatives with interdepartmental resources and/or cross functional stakeholders
• Supports or assists with operational activities that may include, but are not limited to, database management and contract coordination
• Organizing and transforming information into comprehensible structures
• Using data to predict trends in the customer base and the consumer population as a whole
• Performing statistical analysis of data
• Using tools and techniques to visualize data in easy-to-understand formats, such as diagrams and graphs
• Preparing reports and presenting these to leadership
• Engage with providers and quickly move the providers though contracting processes

Senior Network Provider Manager, National Medicaid Ancillary Contracting

Solutions Engineer

• Provide enterprise-level technical leadership across complex, business-critical platforms
• Own and evolve end-to-end solution architecture for highly complex, cross-domain initiatives encompassing application, integration, and data architecture.
• Lead modernization of distributed platforms spanning cloud-native and legacy environments.
• Define and enforce reference architectures for microservices, APIs, event-driven systems, and data platforms.
• Design integration architectures leveraging APIs, event streaming, and asynchronous messaging to decouple systems and enable resilience.
• Define and own data architecture strategies including domain-oriented data models, canonical data definitions, and system-of-record design.
• Design and guide implementation of agent-based and agent-orchestrated architectures to support complex workflows and decision-making.
• Champion AI-assisted software development practices including code generation, refactoring, test creation, impact analysis, and documentation automation.

Principal Architect, Solution Engineering, AI – Architecture

Content Writer

• drafts, reviews, and edits medical, dental and vision plan documents
• support plan document needs for new business by creating plan documents and summaries of benefits and coverage (SBC’s)

Senior Document Writer

• Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness
• Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits
• Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning
• Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality
• Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members
• Collaborates with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences
• Utilizes case management processes in compliance with regulatory and company policies and procedures
• Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation
• Interacts with members/clients telephonically or in person
• May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services
• Travel can be up to 40% of the work week

Registered Nurse, Case Manager

QA Engineer

• Creates and executes the test design and execution strategy for the engineering department coordinating with business, product, development team.
• Develops comprehensive test cases, scripts, and scenarios based on engineering project requirements, ensuring strong coverage of both functional and non‑functional needs.
• Executes functional testing, regression testing and coordinates with business, product, development team to clarify on expected test outcome.
• Own defect creation, re-test after defect fix, close defects.
• Analyzes the complexities of project defects and works closely with quality assurance development teams to investigate and resolve issues.
• Applies in-depth knowledge of quality assurance principles to facilitate the creation of detailed test plans and schedules.
• Communicates with cross-functional engineering teams to reinforce transparency, effective communication, and alignment with quality expectations.
• Completes periodic reviews within the testing environment to ensure configurations match the internal environment.
• Conducts routine assessments in collaboration with the engineering team to measure and monitor performance and quality.
• Configures system applications for test automation efforts to improve coverage, efficiency, and reliability.
• Coordinates with IT infrastructure teams, database administrators, and system analysts to establish and maintain the testing environment.
• Designs complex process improvement initiatives that use quality assurance methodologies to enhance efficiency and effectiveness.
• Conduct User Acceptance Testing.

Quality Engineer – IBMi

Data Scientist

• lead the development of series of customized GenAI solutions
• focus on building scalable, production-grade systems using Python and modern frameworks
• emphasis on generative AI applications such as information retrieval, AI assisted web search, Retrieval-Augmented Generation (RAG)

Data Scientist – GenAI

Analyst

• Simplifying health care one person, one family and one community at a time
• Collaborate with teams to provide better health experience

Medical Claims Analyst

Business Analyst

• Conduct comprehensive evaluation of referred member’s needs/eligibility
• Recommend approach to case resolution and/or meeting needs
• Coordinate and implement assigned care plan activities and monitor care plan progress
• Consult with case managers, supervisors, Medical Directors and/or other health programs
• Identify and escalate quality of care issues through established channels
• Secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs
• Provide coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices

Case Management Analyst

Operations

• Follows processes to assist with processing, insurance verification and authorization
• Analyzes insurance plans and policies
• Ensures compliance with industry-specific regulations
• Identifies opportunities to streamline and optimize insurance verification processes
• Provides exceptional customer service throughout the insurance verification process
• Communicates with insurance providers, brokers, or third-party administrators
• Performs quality assurance checks on insurance verification processes
• Handles complex insurance verification cases
• Provides guidance and support to junior employees