Lead Director, Pharmacy Appeals

Lead Director, Pharmacy AppealsAt CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.The Lead Director, Pharmacy Appeals will lead a team of 40+ colleagues in the management of pharmacy reimbursement appeals, both generic (MAC) and brand (Non-MAC). In this role, you will ensure the appeals are executed under tight Turnaround Times (TATs) and with high accuracy while making sure the team is appropriately staffed and organized. In addition, you will be responsible for developing and implementing solutions and being a lead working with partners to improve and automate processes to increase productivity and fulfill state regulatory changes. You will be leading and coaching the appeal team as well as guiding other internal business units to resolve issues quickly. The Lead Director, Pharmacy Appeals is also responsible for working with the Presidential Response Unit (PRU) to resolve pharmacy appeals submitted directly by state agencies and with the legal and compliance team to ensure state regulatory updates are operationalized. This role requires a thorough knowledge of claim adjudication, internal MAC & non-MAC related processes, and being a leader working with other internal business units to develop new solutions to meet the ever-increasing number of complex appeal bill compliance requirements. The position will be responsible for quality control process to ensure compliance.What You Will DoEstablish processes (with SOPs), capacity / forecast planning, and tools to execute operational service catalogImplement key performance indicators (KPIs) to manage operationsMaintain effective working relationships with a variety of internal and external partners, including PRU, legal, compliance, regulatory, data science, and information technology.Execute process improvements and system enhancements, including coordinating activates across diverse departments and ensure that contributions across different teams are lined and integrated as part of overall deliveryOversee and lead operational teams in finance functionImprove internal processes to demonstrate accuracy and transparency in financial managementCounsel and mentor team members, provide guidance and support to enhance their skills and professional development.Required Qualifications10 year's experience in healthcare industry with experience in price management, optimization or modeling.5+ years directly leading operations teams1+ years' experience with pharmacy appeal related processes and state regulations, and claims adjudication, including claims adjudication logicPreferred QualificationsOutstanding written and oral communication skills, including developing and presenting strategic plans and presentations to executive and technical audiences with the goal of obtaining feedback and alignment on project goals and delivery strategiesRequires exceptional judgment, discretion and confidentialityExcellent leadership skillsProficient in Excel, MS Access, Salesforce, and Pharmacy PortalAbility to work under tight deadlinesStrong mathematical problem-solving skillsPrior PBM KnowledgeFamiliarity with wholesaler invoicesEducationBachelor's Degree or equivalent experience required.Pay RangeThe typical pay range for this role is: $100,000.00 - $231,540.00Great Benefits for Great PeopleWe take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.We anticipate the application window for this opening will close on: 01/31/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. 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.