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The Exec Director of Benefit Operations is responsible for end to end delivery of Medicare and Medicaid Benefits Operations through the ownership of the PBM Annual Enrollment Program (AEP) with responsibility of six workstream and accountability for delivery of the plan administration – requirements, configuration, clinical and quality. The Exec Director has ownership of the successful delivery of Medicare and Medicaid Benefits serving 11+M members and $30+B in revenue ensuring that CMS compliance is achieved with a successful stars rating across multiple Medicare offerings (MAPD, PDP, and EGWP), 12 Medicaid states, and 4 Medicare Medicaid Duals. The Exec Director is directly accountable for ensuring that all plan administration and AEP workstreams (e.g. eligibility, customer care, etc.) are managed in accordance with CVS and CMS standards, and in accordance with agreements contracted with the Client(s).
The Exec Director is responsible for the management of an annual operating budget in excess of $13M, the protection of contractual guarantees and avoidance of millions of Service Warranties that would arise from faulty installation. The Exec Director leads a team of ~70 full time colleagues plus contractors, management across multiple vendor relationships. The Exec Director is responsible for building a high-performing team by providing colleagues with opportunities, guidance, and feedback to and creating a pipeline of talent for future growth is critical to success.
• Ten years of Pharmacy Benefit Managers (PBM) including how a PBM operates and delivers value to clients
• Five years of Benefit and Clinical Operations including how benefits and clinical programs are designed and implemented
• Seven years of extensive understanding of the relationship between the supporting functions of the PBM – including the implications of implementing and supporting regulatory healthcare components (such as Medicaid and Medicare) at the Federal and State Level to ensure CVS and Client adherence to all requirements
• Five years of experience in large and strategic installation and maintenance process – including responding to RFP offered by prospective clients and performance guaranatee avoidance
• Fiv years of Program and Project Management and the creation and management of integrated plans that must be built and managed – with the Clients – to ensure predictable outcomes
• Any additional tasks as directed by supervisor or manager
• Ten to fifteen years of strong communication, both verbal and written, with executive presence
• Ten to fifteen years of Influencing across functions and all levels of an organization
• Ten to fifteen years of progressive leadership experience, manging large or multiple teams, with budget/capital management responsibilities
• Five years of managing client relationships
• Seven years of leading large integrated project plans
• Seven years of driving IT development of systems to meet specific business needs
• Five to ten years of recent resource management (e.g. FTE and vendor)
• Think strategically and tactically
• Lead under pressure and adapt to changing business dynamics
• Create solutions that satisfy multiple clients and market segments
• Ability to work autonomously setting priorities and taking necessary actions to identify, contain, and remediate issues
• Manage multiple and often competing priorities
• Build high performing teams and develop key talent
• Influence continuous improvement across business value streams
• Work across an enterprise to ensure consistency in client delivery
• Drive continuous improvement of Government Benefit Operations through consistency of standars and process
• Travel to clients for meetings, internal meetings and other events as directed
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues 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, religious belief, or other legally recognized reasons that prevents them from being 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 or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
• Current tools or applications used to manage Benefit Operations – such as RxClaim, Formulary Management System, SFDC, Tableau
• Industry advancements in core PBM & clinical functionality (such as use of AI for adjudication)
• Familiarity with software development life cycle
• Advanced Organizational Leadership competencies
• Formal Process Improvement methodologies (such as LEAN/SS, CMM-I, ISO)
• Influence continuous improvement of upstream and downstream processes that are impactful to area of ownership (e.g., Medical Affairs, Clinical Advisor(s), Account Management, Networks, Digital, etc.)
• Conduct cross-functional Root Cause Detection in keeping with Caremark Service Excellence best practices (e.g., Medical Affairs, Clinical Advisor(s) Account Management, Networks, Digital, Product, Configuration, Quality, etc.)
Bachelors degree or equivalent work experience.
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand – with heart at its center – our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.