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CVS Health Contract Compliance Consultant - Senior in Woonsocket, Rhode Island

Job Description

The Contract Compliance Consultant - Senior will be responsible to ensure contractual and regulatory compliance as it relates to third party programs. Act as a liaison between internal departments and external contacts such as health plans, processors, pharmacy benefit managers (PBM), and governmental agencies. Facilitate the initiation and on-going maintenance of pharmacy system to ensure that CVS pharmacies are able to service and bill prescriptions for patients of third party programs, where CVS is contracted and/or enrolled.


•Third Party Information Management

• Make informed decisions by thoroughly reviewing communications distributed by PBMs, processors, health plans, state Medicaid and Medicare, relative to prescription and/or medical claim processing

• Serve as a subject matter expert for both internal and external representatives by researching prescription insurance program requirements, medical billing policies, compliance inquiries, and related issues/complaints, and crafting timely responses

• Demonstrate care by proactively identifying and resolving potential Third Party operational issues

• Understand the terms of Payer contracts, and NCPDP Standards, to ensure CVS and plan compliance

• Translate, and clarify where needed, payer information and communicate to appropriate internal personnel, field management, and CVS pharmacy locations

• Compose third party articles for the Payer Relations Weekly Update, issue emergency communications via the pharmacy HUB, and post Medicaid related third party program requirements on the Intranet, as necessary

Relationship Building

• Foster and maintain a professional effective working relationship with contracted agencies, PBMs, and health plans

• Problem solving point of contact for complaints and inquiries received from payers on behalf of our mutual customers

• Collaborate with payers, internal departments, and field personnel, to implement process improvements for prescription and/or medical claim processing, to ensure program compliance and to enhance store level customer service

• Keep Payer Relations Contracting Directors and/or appropriate management apprised of problematic Payer related issues that may significantly impact prescription processing

•Plan Code Facilitation

• Evaluate third party information to determine if an internal system update is required

• Track plan changes via database, and prepare necessary documentation to facilitate new third party plan codes and/or updates to existing codes

• Collaborate with appropriate internal Payer Relations team(s) to determine best approach for system updates, when needed

• Focus on the customer by addressing prescription processing escalations received from various internal departments and pharmacy teams

• Contribute to a high-performing team by looking for opportunities to achieve individual and broader team goals, while remaining flexible for changing business needs, to enable supportive, collaborative, and management of challenging work

• Assist with implementation of procedures, policies, and other projects as needed, to develop processes for efficient day to day payer and customer support

VITAL SKILLS: In order of importance, list specific skills or talents that a qualified incumbent should possess (i.e., management of large staff, computer applications, subject knowledge, etc.)

  1. Excellent verbal and written communication skills

  2. Professionalism, attention to detail, and flawless execution

  3. Think independently and offer solutions

  4. Ability to problem solve , multi-task, and prioritize

  5. Proven ability to collaborate with a variety of both internal and external representatives

  6. Excellent organizational skills

Required Qualifications

3+ years of healthcare or pharmacy experience

3+ years of experience with Microsoft Office, including Excel, Access, and PowerPoint

Preferred Qualifications

Pharmacy Industry experience preferred


Bachelor's Degree or equivalent years of related professional experience in combination with years of education may be considered in lieu of a degree

Business Overview

It’s a new day in health care.

Combining CVS Health and Aetna was a transformative moment for our company and our industry, establishing CVS Health as the nation’s premier health innovation company. Through our health services, insurance plans and community pharmacists, we’re pioneering a bold new approach to total health. As a CVS Health colleague, you’ll be at the center of it all.

We offer a diverse work experience that empowers colleagues for career success. In addition to skill and experience, we also seek to attract and retain colleagues whose beliefs and behaviors are in alignment with our core values of collaboration, innovation, caring, integrity and accountability.

CVS Health is an equal opportunity/affirmative action employer. Gender/Ethnicity/Disability/Protected Veteran – we highly value and are committed to all forms of diversity in the workplace. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities. We comply with the laws and regulations set forth in the following EEO is the Law Poster: EEO IS THE LAW at https://www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf and EEO IS THE LAW SUPPLEMENT at https://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm . We provide reasonable accommodations to qualified individuals with disabilities. If you require assistance to apply for this job, please contact our Advice and Counsel Reasonable Accommodations team at mailto:AdviceCounsel@cvshealth.com . Please note that we only accept applications for employment via this site.

If technical issues are preventing you from applying to a position, contact Kenexa Helpdesk at 1-855-338-5609 or cvshealthsupport@us.ibm.com . For technical issues with the Virtual Job Tryout assessment, contact the Shaker Help Desk at 1-877-987-5352.