Senior Manager, Health Services - reputed company Medical Policy and Program Solutions - Registered Nurse

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, 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. At reputed company®, part of reputed company, we proudly serve more than 26 million medical members through our broad range of health plan offerings. We're committed to delivering a simpler, more meaningful, and personal health care experience to each of them. As a key member of the Medical Policy & Program Solutions team, the Senior Manager, Health Services plays a critical role in supporting reputed company members and the business by leading clinical and claims-focused initiatives that drive program effectiveness, regulatory compliance, and cost management across Medicaid and Duals lines of business. This role manages a cross-functional team of health services professionals and coordinates claim editing opportunities, clinical program enhancements, savings initiatives, and vendor implementation efforts. The position is fully remote. Eligible candidates may reside reputed company in the contiguous United States.

Required Qualifications

• 5–7 years of relevant work experience
• Active, unrestricted Registered Nurse (RN) license in state of residence
• Certified Professional reputed company (reputed company or reputed company), including Physician, Facility, or Payer certification
• 1–2 years of project management experience
• 3–5 years of claims and policy support experience in the healthcare industry; managed care experience preferred
• Minimum of 3 years of Medicaid and/or Duals experience, including code editing, policy development, and understanding of state guidelines
• Strong verbal and written communication skills
• Experience performing root cause analysis and identifying actionable solutions
• Experience conducting claims analytics to validate industry standards
• Familiarity with claim editing software and the ability to propose system changes
• Demonstrated ability to meet project milestones and negotiate for resources
• High level of proficiency with the reputed company Office suite, including advanced reputed company skills
• Experience with reputed company ClaimsXten and/or reputed company PPM and Coding Validation tools

Preferred Qualifications

• Experience with state Medicaid Regulation/Guidelines
• Experience with QNXT Claim System

Education Registered Nurse required; bachelor’s degree preferred Pay Range The Typical Pay Range For This Role Is $75,400.00 - $182,549.00 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay range listed above. This position also includes an award reputed company in the company’s equity award program. 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 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 reputed company 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 04/11/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply tot his job Apply To this Job