Executive Director, Clinical Service Operations

The Executive Director, Clinical Services Operations in Prior Authorizations (PA) role will provide strategic leadership and clinical oversight of six key operations teams and their corresponding operational functions. This leader will be responsible for leading the implementation, compliance, delivery, and execution of the PA programs across our book of business for Commercial, Exchange, and Medicaid clients.

You will be accountable for achieving the operational targets for compliance, execution, member/beneficiary & provider service experience, client retention, revenue growth and lowest cost to service expense strategy.

You will be leading and attaining the following business objectives:

• Support of all audit activities (internal, mock, client, State and CMS) related to Commercial/Medicaid PA operations including annual CMS timeliness audit and frequent renewal of NCQA/URAC PBM accreditations.
• Managing 1,800+ clinical internal/contingent workforce colleagues comprised of technicians, clinicians and pharmacists primarily operating in a Work from Home (WFH) environment.
• Ensure compliance with all appropriate regulations – federal and state, accreditation standards – URAC and NCQA, client requirements, and performance guarantees.
• Annual PBM revenues totaling over $127+ million.
• Provide oversight, governance, and management of all clinical operational outcomes of the Prior Authorization and Formulary Exceptions programs.
• Partner with the Product team to develop and implement strategies that will grow the number of lives covered and generate incremental revenue for the PBM while providing client savings.
• Saving clients in the excess of $12B in drug savings annually.
• Ensure consistent processes and adopt best practices across diverse and complex PA lines of business which are made up of varying regulatory and client commitments.
• Vendor relationship management with Medical Necessity Review Organizations (MNRO) to ensure that appropriate level of clinical review is applied to PA and Appeals cases.
• Lead across a complex environment to execute over 8 million Prior Authorization and appeal cases annually.
• Close and frequent collaboration with enterprise business partners in Medical Affairs, Product, Information Technology (IT), Pharmacy Operations, Finance, Accreditation, HR, Legal, and Regulatory Affairs to drive success with current programs, labor expense initiatives, and future strategies.
• Drive productivity and quality improvements through process streamlining and automation year over year to achieve best in class service and lowest cost to serve.
• Strong emphasis on operations’ employee recognition, coaching and development, and engagement.
• Annual OPEX budget totaling approximately $150+ million.
• Relationship management and client retention for over 1,600 clients that delegate their clinical PA responsibilities to CVS Caremark Clinical Operations team.
• Deliver on our goals to prevent multi-million-dollar performance guarantee payouts and other monetary penalties such as Service Warranties.
• Manage labor budget while driving process improvement and productivity strategies to deliver the lowest cost serve rate in the industry.

Pay Range
The typical pay range for this role is:
Minimum: 131,500
Maximum: 297,250

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (PTO) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit

jobs.CVSHealth.com/benefits

Required Qualifications

• Ability to lead a large operation cross functional team
• Must be able to travel as needed, per business needs
• 10 plus years of PBM/Healthcare experience
• 15 plus years of prior relevant experience (in operations environment)
• Ability to work in a hybrid model (in office Tuesday/Wednesday/Thursday)

Preferred Qualifications
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Education

• Bachelor’s degree or equivalent years of experience

Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. 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. 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.