Project Manager

Job Description
National High Dollar Review Team is seeking to add a supporting project management position to the staff to better manage the high dollar claim review process. This position is very visible at a regional and national level. You will have an opportunity to work with Network Management Leadership as well as the National team. Ideal candidates will be a clinical resource, potentially with some claim experience. The candidate selected for this position will be a member of the National High Dollar Review unit. Project Manager will be responsible for administration of the high dollar claims review and approval process for multiple markets as assigned. Responsibilities include: 1. Act as point person for intake/output with multiple business partners including Medical Claims Management, Network and Approvers for Payment of the high dollar claims. 2. Keeps multiple High Dollar Review requests moving at the same time. 2. Complete Quick Base data entry for efficient management of high dollar claim inventory/review. 3. Review claims and complete the following: • Check that member is in High Dollar Claim Forecast tool • Check that member has been actively managed by Patient Management • Verify that COB has been recently updated • Verify Eligibility (including newborn eligibility) • Determine if the claim is eligible for Subrogation • Review # of days paid, compared to allowed amount • Question high $$ drug/supply carve outs • Obtain any additional information necessary for review 4. Attend weekly process calls, work nationally and regionally to improve process 5) Provider regular reporting to Market leadership. 6) Calculate savings associated with the project. 7) Navigates systems efficiently. Experience with provider contracting, claims management and patient management is preferred. Experience with Aetna systems (EPDB, eTUMS, ASD, HRP) is preferred.

Required Qualifications
Experience with project management support of projects that are multi faceted and include cross functional collaboration between multiple departments Experience in provider contracting, provider relations; claims mngmnt, patient mngmnt &d with Aetna systems (EPDB, eTUMS, ASD) is preferred. 2-4 years' experience in a Claims environment that includes HMO, HRP and Traditional claim platforms.

Preferred Qualifications
This is a highly visible position and requires the following: Ability and perseverance to research across the organization to locate information and solve problems. Ability to communicate effectively with all levels of management. Ability to communicate with and influence peers, business partners and management. Ability to effectively collaborate across the organization.

Bachelor's Degree

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.