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About the Role

CVS Health is transforming healthcare by making it more accessible, affordable, and easier to navigate. This role is pivotal in translating affordability strategies into real-world prescription processing outcomes, focusing on pharmacy adjudication, patient access, and benefit optimization. The Manager will design, execute, and improve adjudication logic and plan sequencing strategies to maximize patient benefits and enable scalable affordability solutions.

Responsibilities

Serve as a subject matter expert in prescription adjudication, with deep expertise in Coordination of Benefits (COB) sequencing rules, NCPDP standards and transaction logic, and plan design constraints.
Design, configure, and optimize complex plan sequencing strategies that maximize utilization of patient benefits, adjust dynamically based on patient profile, treatment type, and out-of-pocket cost, and enable the lowest appropriate cost outcome while maintaining compliance.
Partner with senior leadership to translate affordability strategies into executable adjudication logic and workflows.
Support the development of curated affordability journeys by ensuring adjudication pathways reflect real-world patient scenarios and enable effective routing across benefits, coupons, discount cards, and cash options.
Continuously evaluate and refine sequencing rules based on claims performance, reject patterns, patient cost outcomes, abandonment signals, and evolving payer rules and market dynamics.
Identify, quantify, and prioritize patient affordability opportunities using pharmacy claims and performance data to reduce out-of-pocket costs and cost-related abandonment.
Develop and maintain analytics, reporting, and diagnostic frameworks to monitor claim success, reject trends, affordability pathway performance, and patient out-of-pocket cost exposure.
Translate complex adjudication scenarios, plan interactions, and sequencing logic into clear, actionable insights for cross-functional partners and leadership.
Support test-and-learn approaches by measuring the impact of new affordability strategies and recommending optimization opportunities.
Inform and shape affordability strategies based on adjudication feasibility and constraints.
Evaluate new savings concepts and their applicability within existing plan and regulatory frameworks.
Support the design and build of scalable affordability solutions.
Translate affordability and sequencing requirements into detailed system specifications and enhancements.
Support development, configuration, and integration of adjudication capabilities across platforms.
Ensure solutions are operationally viable and patient-centric.
Partner with Pharmacy Operations to align workflows with in-store execution realities and patient experience needs.
Manage multiple concurrent initiatives, balancing priorities, timelines, and interdependencies across stakeholders.
Support end-to-end execution of adjudication and affordability initiatives, including requirements refinement, configuration validation, UAT planning and execution, and defect identification and resolution.
Validate that adjudication logic performs as intended across primary and secondary benefit routing, coupon and discount integration, and exception and re-adjudication scenarios.
Monitor post-launch performance and identify issues impacting cost, claim success, or patient experience.
Recommend and implement iterative improvements to sequencing and workflows.
Partner with analytics and IT teams to ensure data integrity and consistent performance tracking.
Ensure all affordability and adjudication solutions adhere to regulatory requirements, contractual obligations, and NCPDP standards and billing rules.
Support appropriate and compliant configuration of adjudication logic and COB sequencing.
Interpret evolving requirements, assess risks within affordability pathways, and ensure consistency and defensibility of solutions.
Contribute to governance processes by documenting logic, decisions, and requirements to support audit readiness and operational transparency.

Requirements

5–7 years of experience in adjudication, pharmacy operations, PBM operations, healthcare technology, or analytics.
Strong analytical and problem-solving skills.
Experience collaborating across teams and influencing outcomes.
Excellent communication and presentation skills.
Proficiency in Excel and PowerPoint.
7+ years experience with affordability programs such as coupons or discount card processing or contracting.
Knowledge of pharmacy adjudication or COB processes.
NCPDP membership experience
Experience with UAT, testing, or IT collaboration.
Experience working in cross-functional environments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Skills

Coordination of Benefits (COB) sequencing rules
NCPDP standards and transaction logic
Plan design constraints
Pharmacy adjudication
Benefit optimization
Excel
PowerPoint

Location

Remote

Work Type

Full time

Experience Level

5-7 years
7+ years

Education Level

Bachelor’s degree or equivalent experience in pharmacy, analytics, or operations.

Salary/Compensations

$66,330.00 - $145,860.00

Benefits

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs

About the Company

CVS Health is 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.
CVS Health is on a mission to transform healthcare by making it more accessible, affordable, and easier to navigate for the patients we serve.
The company is reimagining how prescriptions are processed, priced, and delivered—leveraging its scale, clinical expertise, and 10,000‑store footprint to improve patient outcomes and reduce cost-related barriers to care.

Equal Opportunity

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.