Position SummaryThe Manager, MPPS Pharmacy Policy Management is responsible for supporting the development, operationalization, monitoring, and continuous improvement of Medical Pharmacy (Med Rx) policies across Commercial, Medicare, and Medicaid lines of business. This role supports MPPS leadership to ensure medical pharmacy policies are clinically appropriate, operationally executable, and consistently applied. They oversee pharmacy policy management which includes coding accuracy, business rule translation, quality assurance, and regulatory compliance activities supporting provider-administered medications, specialty pharmaceuticals, biosimilars, infusion therapies, and emerging drug technologies. The position is accountable for driving operational excellence, reducing policy-related defects, and improving claim payment accuracy.
Medical Pharmacy Policy Ideation- Lead the identification of new and emerging pharmacy policy opportunities, standardizing across lines of business.
- Develop detailed business requirement documents for pharmacy policies.
- Ensure accurate translation of policy intent into claims processing rules, utilization management workflows, and reimbursement methodologies.
- Support policy enablement processes, as assigned.
Quality Assurance & Defect Remediation- Align coding and reimbursement logic with Medical Pharmacy policy intent.
- Establish quality monitoring programs supporting Medical Pharmacy policy implementation and operational execution.
- Lead root cause analyses for policy defects, configuration issues, coding inaccuracies, and operational failures for pharmacy policies.
- Ensure audit readiness and maintenance of supporting documentation.
Analytics & Performance Management- Develop and monitor key performance indicators (KPIs) supporting Medical Pharmacy policy effectiveness.
- Utilize data analytics to identify utilization trends, operational gaps, coding defects, and cost-saving opportunities.
- Support internal audits, external audits, compliance reviews, and corrective action initiatives.
May reside anywhere in the US
Required Qualifications- 3+ years of policy & business analytics experience.
- Certified Professional Coder (CPC), Certified Pharmacy Technician (CPhT), or agreement to obtain CPC within one year of hire in the role.
- Experience partnering with cross-functional stakeholders across clinical, operational, and technical teams.
- Experience with translating data analytics to insights.
Preferred Qualifications- Knowledge of specialty pharmaceuticals, provider-administered drugs, biosimilars, infusion therapies, and emerging therapeutic categories.
- Knowledge of Medicare Part B drug management and reimbursement.
- Experience with specialty drug cost-management programs and affordability initiatives.
- Knowledge of Payment Integrity and medical drug claim editing platforms.
Education- Bachelor's degree in pharmacy, healthcare administration, or related discipline or equivalent combination of education and relevant experience.
Anticipated Weekly Hours40
Time TypeFull time
Pay RangeThe typical pay range for this role is:
$54,300.00 - $145,860.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 09/07/2026
