Project Program Management Medical & Payment Policy Senior Manager

Position Overview The Senior Manager, Medical and Payment Policy Performance Research and Correct Coding Analysis independently develops and manages assigned policy and coding reviews by evaluating clinical and payment policies and identifying potential issues. This position ensures coding aligns with defined medical and pre‑payment policies, identifies opportunities to optimize performance, and supports organizational goals and regulatory requirements. The role partners closely with claims operations to apply policy intent across end‑to‑end claims processing (intake, edits, adjudication, denials, appeals, and adjustments) and to drive consistent, compliant outcomes. Key Responsibilities Collaborate with cross‑functional teams – such as IT, compliance, operations, and provider relations – to ensure seamless integration of claims coding changes and resolve complex configuration issues. Monitor and report on claims coding and configuration accuracy, trends, and key performance indicators (KPIs), providing actionable insights for process improvement. Leverage claims processing experience to evaluate end‑to‑end workflows (front‑end edits, adjudication logic, denials, appeals, and adjustments) and translate findings into actionable policy/coding guidance and claims platform configuration or testing support. Stay up to date with industry developments, payer and provider requirements, and regulatory changes affecting claims coding and configuration. Develop and maintain documentation for identifying claims trends, pinpointing policy or coding issues, and communicating required configuration changes across claims platforms. Lead or participate in audits and reviews related to claims coding and configuration, ensuring readiness and timely resolution of findings. Provide expert guidance on correct coding practices, resolving complex coding issues and supporting audits as needed. Required Qualifications 5+ years of experience in healthcare claims administration, coding, or configuration. Proven expertise in configuration testing, defect management, and process optimization specifically for medical and pre‑payment policy. Strong analytical, organizational, and problem‑solving skills. Excellent communication and interpersonal abilities, with experience collaborating across technical and non‑technical teams. Proficiency with claims adjudication platforms, testing tools, and data analysis applications. Preferred Skills & Competencies Project management certification (e.g., PMP, Lean Six Sigma) preferred. Experience with system migrations, medical and pre‑payment configuration changes, or healthcare technology implementations. 3‑5 years claims processing systems experience, including HRP, ACAS and QNXT coding methodologies (ICD, CPT, HCPCS), and regulatory requirements (e.g., CMS, HIPAA). Ability to manage multiple priorities in a fast‑paced, dynamic environment. Commitment to continuous improvement and operational excellence. Education Bachelor's degree in Healthcare Administration, Information Systems, Business, or equivalent experience. Certified Coding Specialist required. License Practical Nurse (LPN) or RN preferred. Pay Range The typical pay range for this role is: $67,900.00 - $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. Great benefits for great people 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr Hispanic Alliance for Career Enhancement