The role can be located in either:
Plano, TX, Hartford, CT, Atlanta, GA, Cranberry, PA, Cary, NC or Concord, CA.
We are seeking an analytical professional to join our Medical Economics - Medical Expense Review (MER) team. The primary goals of this team are to a) identify and communicate with leadership specific provider, procedure and population level trends and outliers impacting the plan sponsor and local market medical cost trends, and b) analyze and size potential savings initiatives in coordination with clinical and network leads.
Fundamental Components/Job Description
Analyze and research medical costs drivers - including trend drivers driving the largest financial impact and critical outliers when compared to benchmarking analyses.
Critical to the role is the ability to transform data findings and tell a cohesive story to our Account, Clinical, Network, and Finance leadership using data visualizations and PowerPoint exhibits.
Evaluate provider and procedure patterns at the claims detail level, in order to spot possible reimbursement issues or suspect utilization practices.
Support the development of contracting, clinical policy, or benefit design savings initiatives ("scoreable action items"); Consult with network and clinical management on opportunities to model and size the financial impact of improved utilization patterns and contracting activities.
Own, track and document all aspects of related work from beginning to end of a project.
3+ years of experience in the managed care industry with knowledge of provider contracting, provider reimbursement, patient management, product, benefits design or related experience.
2+ year experience within analytics of finance or related experience
Experience working with medical and pharmacy Claims
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.
Experience in within the healthcare industry
Experience with key managed care functions including provider contracting, benefit design, medical management as well as knowledge of business functions and impact on financials (underwriting, sales, product development, network management)
Experience with SAS Enterprise Guide
Bachelor's degree or equivalent experience
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. 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.