Senior Manager, Project Program Management (Claim Operations)

Responsibilities A. Designs, develops, and leads the Aetna Business Unit Claim Operations Review program, providing 1) ongoing assessments of the health of end-to-end claim operational and financial flows, 2) analysis of operational issues, and 3) insight into factors in the operational environment that could affect the actuarial reserve setting process. B. Leads and oversees the construction of analysis and presentation deck by members of the Claim Operations Analytics team; presents the materials during the twice-monthly Operations Review Calls. C. Designs, conducts, or leads ad hoc operational analysis to meet Service Operations information needs. D. Maintains various routine reports and information sources supporting Commercial and Medicare Service Operations constituents. Required Qualifications In-depth understanding of the medical/dental claim operational lifecycle including: Provider Billing/coding process, Claim Intake & Distribution, Pre-adjudication process, Claim editing, Pended Claim Inventory management, Auto-adjudication, Payment Process, Appeals, and Rework. Demonstrated understanding of actuarial reserving concepts and the interaction between claim operations and reserve modeling. 5 years’ experience designing appropriate metrics and conducting “large population” (100K+) claim analyses to monitor and evaluate the quality and speed of operational flows through claim lifecycle phases. 5 years’ experience developing and delivering professional analytical presentations to senior leaders. Demonstrated adaptability to changing operational conditions, including development of innovative approaches for understanding the impact of an evolving operational environment. Demonstrated experience in peer leadership: leading others through influence, rather than through formal organization authority. MS Excel power-user. 3 years' SQL, SAS, GCP or related query-construction experience. Preferred Qualifications 3+ years’ experience with Aetna claim systems and operational environment. 3+ years’ hands‑on experience querying large-scale raw operational claim data sets, including data cleaning and conditioning. Pay Range The typical pay range for this role is: $82,940.00 - $182,549.00. 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. This position also includes an award target in the company’s equity award program. Benefits 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. EEO Statement Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr