Manager, Pharmacy Adjudication & Affordability

We’re 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. Position Summary CVS Health is on a mission to transform healthcare by making it more accessible, affordable, and easier to navigate for the patients we serve. As a critical part of this effort, 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. The Manager, Adjudication & Affordability plays a pivotal role in translating affordability strategies into real-world prescription processing outcomes. This role sits at the intersection of pharmacy adjudication, patient access, and benefit optimization—leveraging deep expertise in Coordination of Benefits (COB) sequencing, NCPDP standards, and plan design to ensure patients receive the most affordable and appropriate medication pathway available. This Manager will be responsible for designing, executing, and continuously improving adjudication logic and plan sequencing strategies that maximize patient benefits, dynamically adjust for cost drivers, and enable scalable affordability solutions across the CVS ecosystem. The role requires strong analytical rigor and hands-on execution, including active involvement in configuration validation, UAT, and post-launch optimization. Working cross-functionally with Trade, Growth, Payer Relations, IT, Digital, and Pharmacy Operations, this individual will help shape and operationalize innovative affordability solutions—from early-stage ideation through implementation—ensuring they are technically feasible, compliant, and impactful for patients. The ideal candidate brings a deep understanding of pharmacy adjudication and benefit structures, strong problem-solving capability, and the ability to translate complex scenarios into actionable insights. This role demands a highly collaborative operator who can navigate ambiguity, influence partners, and deliver measurable improvements in patient affordability, claim success, and overall pharmacy experience. Key Responsibilities: Plan Sequencing Strategy, Adjudication Design, and Affordability Enablement Serve as a subject matter expert in prescription adjudication, with deep expertise in: Coordination of Benefits (COB) sequencing rules NCPDP standards and transaction logic Plan design constraints across PBM, retail, and third-party affordability programs 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 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 (insured, underinsured, uninsured) Enable effective routing across benefits, coupons, discount cards, and cash options Continuously evaluate and refine sequencing rules based on: Claims performance and reject patterns Patient cost outcomes and abandonment signals Evolving payer rules and market dynamics Affordability Analytics & Insights 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 and reject trends Affordability pathway performance 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. Cross-Functional Solution Development & Execution Partner across Trade, Growth, and Payer Relations to: 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 Collaborate with IT and Digital teams to: 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. Adjudication Execution, Testing, and Optimization Support end-to-end execution of adjudication and affordability initiatives, including: Requirements refinement Configuration validation UAT planning and execution Defect identification and resolution Validate that adjudication logic performs as intended across: Primary and secondary benefit routing Coupon and discount integration 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. Compliance & Governance Support Ensure all affordability and adjudication solutions adhere to: Regulatory requirements Contractual obligations NCPDP standards and billing rules Support appropriate and compliant configuration of adjudication logic and COB sequencing. Partner with Legal, Compliance, and Payer Relations teams to: Interpret evolving requirements Assess risks within affordability pathways Ensure consistency and defensibility of solutions Contribute to governance processes by documenting logic, decisions, and requirements to support audit readiness and operational transparency. Required Qualifications 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. Preferred Qualifications 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. Education Bachelor’s degree or equivalent experience in pharmacy, analytics, or operations. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $66,330.00 - $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. 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. Great benefits for great people We 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: 07/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.