CrawlJobs Logo

Manager, Clinical Adjudication Prior Authorization Solutions

https://www.cvshealth.com/ Logo

CVS Health

Location Icon

Location:
United States

Category Icon
Category:
-

Job Type Icon

Contract Type:
Not provided

Salary Icon

Salary:

60300.00 - 145860.00 USD / Year
Save Job
Save Icon
Apply Position

Job Description:

The Clinical Adjudication Prior Authorization Support (CAPAS) Team delivers end-to-end support for Member Prior Authorization (PA) override services, working in close partnership with internal stakeholders and external clients. As subject matter experts in PA override functionality, CAPAS drives enterprise-wide initiatives and ensures operational excellence—particularly in the configuration and management of override records within the RxClaim platform.

Job Responsibility:

  • Lead and close deliverables related to department initiatives and PA activities in a timely manner
  • Support CAPAS service catalog offerings
  • Maintain CAPAS service-related job aids and documentation
  • Drive innovative improvements across CAPAS operations
  • Validate functionality of new programs and innovations
  • Support implementation of client PA files during the clinical review portion of member data transitions
  • Assist partners in understanding adjudication claim processing
  • Provide training and cross-training to internal CAPAS team members, including new hires and advanced deep-dive sessions
  • Conducting research in RxClaim
  • Documenting business requirements for IT initiatives
  • Consulting on clinical testing efforts
  • Identifying root causes of adjudication issues
  • Supporting leadership activities and escalating risks as needed
  • Maintain PA records in RxClaim, upload and update authorizations, research member configurations, run PA Queries to extract configuration data, generate reports, and contribute to process improvement and automation initiatives

Requirements:

  • Minimum 5 years of experience with RxClaim, specifically in adjudication related to Prior Authorization overrides
  • Experience running queries in RxClaim and/or Data Warehouses
  • Advanced proficiency in Microsoft Office Suite, particularly Excel, Access, and Visio
  • Bachelor’s degree required
  • equivalent work experience may substitute
  • Strong problem-solving and decision-making skills
  • Proven ability to collaborate effectively across teams
  • Demonstrated growth mindset, with agility in learning and developing self and others
  • Strong execution and delivery skills, including planning, implementation, and support
  • Self-motivated with a positive, proactive attitude
  • Excellent communication and organizational skills, with the ability to clearly articulate complex technical concepts to non-technical audiences

Nice to have:

  • Knowledge of CVS Caremark clinical programs (e.g., Benefit plan setup, formularies, utilization management)
  • Experience developing or enhancing training materials
  • Familiarity with Microsoft Power Platform
What we offer:
  • Affordable medical plan options
  • 401(k) plan (including matching company contributions)
  • Employee stock purchase plan
  • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
  • Paid time off
  • Flexible work schedules
  • Family leave
  • Dependent care resources
  • Colleague assistance programs
  • Tuition assistance
  • Retiree medical access

Additional Information:

Job Posted:
February 25, 2026

Expiration:
February 28, 2026

Employment Type:
Fulltime
Work Type:
Remote work
Icon
CVS Health - All Job Offers
Job Link Share:
Copy Link Icon
Facebook Icon Twitter Icon LinkedIn Icon

Looking for more opportunities? Search for other job offers that match your skills and interests.

Briefcase Icon

Similar Jobs for Manager, Clinical Adjudication Prior Authorization Solutions

Authorization and Claims Analytics Data Analyst III

The Authorization and Claims Analytics Data Analyst III serves as a Subject Matt...
Location
Location
United States , Los Angeles
Salary
Salary:
88854.00 - 142166.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree (or equivalent education/experience)
  • At least 4 years of experience in analytics, with substantial exposure to healthcare operations, managed care, or population health
  • Experience leading end-to-end analytic projects, including requirements gathering, data validation, analysis, and delivery of insights
  • Experience analyzing multiple data sources and translating findings into actionable recommendations
  • Experience with Utilization Management (UM) authorization workflows and prior authorization metrics
  • Expert in SQL for complex exploratory analysis, data modeling, and ETL processes
  • Advanced proficiency in Tableau (or equivalent BI tools)
  • Strong statistical and analytical skills, including multivariate analyses, regression, and control charts
  • Knowledge of version control (Git, GitHub) and collaborative development workflows
  • Ability to develop and maintain reusable analytic frameworks, templates, and processes
Job Responsibility
Job Responsibility
  • Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights
  • Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance
  • Coordinates with IT and product owners to ensure analytic outputs are integrated into enterprise systems and recurring workflows
  • Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards
  • Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases
  • Maintains awareness of data lineage and governance compliance throughout all analytic work
  • Manages project planning, tracking, and post-implementation assessment for assigned deliverables
  • Mentors and models adherence to analytic development best practices
  • Applies subject matter expertise in evaluating business operations and processes
  • Identifies areas where technical solutions would improve business performance
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

Authorization and Claims Analytics Data Analyst III

The Authorization and Claims Analytics Data Analyst III serves as a Subject Matt...
Location
Location
United States , Los Angeles
Salary
Salary:
88854.00 - 142166.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree (or equivalent education/experience)
  • At least 4 years of experience in analytics, with substantial exposure to healthcare operations, managed care, or population health
  • Experience leading end-to-end analytic projects, including requirements gathering, data validation, analysis, and delivery of insights
  • Experience analyzing multiple data sources and translating findings into actionable recommendations
  • Experience with Utilization Management (UM) authorization workflows and prior authorization metrics
  • Expert in SQL for complex exploratory analysis, data modeling, and Extract, Transform, and Load (ETL) processes
  • Advanced proficiency in Tableau (or equivalent BI tools)
  • Strong statistical and analytical skills, including multivariate analyses, regression, and control charts
  • Knowledge of version control (Git, GitHub) and collaborative development workflows
  • Ability to develop and maintain reusable analytic frameworks, templates, and processes
Job Responsibility
Job Responsibility
  • Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights
  • Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance
  • Coordinates with IT and product owners to ensure analytic outputs are integrated into enterprise systems and recurring workflows
  • Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards
  • Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases
  • Maintains awareness of data lineage and governance compliance throughout all analytic work
  • Manages project planning, tracking, and post-implementation assessment for assigned deliverables
  • Mentors and models adherence to analytic development best practices
  • Applies subject matter expertise in evaluating business operations and processes
  • Identifies areas where technical solutions would improve business performance
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

Authorization and Claims Analytics Data Analyst III

The Authorization and Claims Analytics Data Analyst III serves as a Subject Matt...
Location
Location
United States , Los Angeles
Salary
Salary:
88854.00 - 142166.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree (or equivalent education/experience)
  • At least 4 years of experience in analytics, with substantial exposure to healthcare operations, managed care, or population health
  • Experience leading end-to-end analytic projects, including requirements gathering, data validation, analysis, and delivery of insights
  • Experience analyzing multiple data sources and translating findings into actionable recommendations
  • Experience with Utilization Management (UM) authorization workflows and prior authorization metrics
  • Expert in SQL for complex exploratory analysis, data modeling, and Extract, Transform, and Load (ETL) processes
  • Advanced proficiency in Tableau (or equivalent BI tools)
  • Strong statistical and analytical skills, including multivariate analyses, regression, and control charts
  • Knowledge of version control (Git, GitHub) and collaborative development workflows
  • Ability to develop and maintain reusable analytic frameworks, templates, and processes
Job Responsibility
Job Responsibility
  • Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights
  • Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance
  • Coordinates with IT and product owners to ensure analytic outputs are integrated into enterprise systems and recurring workflows
  • Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards
  • Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases
  • Maintains awareness of data lineage and governance compliance throughout all analytic work
  • Manages project planning, tracking, and post-implementation assessment for assigned deliverables
  • Mentors and models adherence to analytic development best practices
  • Applies subject matter expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed
  • Perform other duties as assigned
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

Authorization and Claims Analytics Data Analyst III

The Authorization and Claims Analytics Data Analyst III serves as a Subject Matt...
Location
Location
United States , Los Angeles
Salary
Salary:
88854.00 - 142166.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree (or equivalent education/experience)
  • At least 4 years of experience in analytics, with substantial exposure to healthcare operations, managed care, or population health
  • Experience leading end-to-end analytic projects, including requirements gathering, data validation, analysis, and delivery of insights
  • Experience analyzing multiple data sources and translating findings into actionable recommendations
  • Experience with Utilization Management (UM) authorization workflows and prior authorization metrics
  • Expert in SQL for complex exploratory analysis, data modeling, and Extract, Transform, and Load (ETL) processes
  • Advanced proficiency in Tableau (or equivalent BI tools)
  • Strong statistical and analytical skills, including multivariate analyses, regression, and control charts
  • Knowledge of version control (Git, GitHub) and collaborative development workflows
  • Ability to develop and maintain reusable analytic frameworks, templates, and processes
Job Responsibility
Job Responsibility
  • Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights
  • Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance
  • Coordinates with IT and product owners to ensure analytic outputs are integrated into enterprise systems and recurring workflows
  • Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards
  • Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases
  • Maintains awareness of data lineage and governance compliance throughout all analytic work
  • Manages project planning, tracking, and post-implementation assessment for assigned deliverables
  • Mentors and models adherence to analytic development best practices
  • Applies subject matter expertise in evaluating business operations and processes
  • Identifies areas where technical solutions would improve business performance
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

Authorization and Claims Analytics Data Analyst III

The Authorization and Claims Analytics Data Analyst III serves as a Subject Matt...
Location
Location
United States , Los Angeles
Salary
Salary:
88854.00 - 142166.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree (or equivalent education/experience)
  • At least 4 years of experience in analytics, with substantial exposure to healthcare operations, managed care, or population health
  • Experience leading end-to-end analytic projects, including requirements gathering, data validation, analysis, and delivery of insights
  • Experience analyzing multiple data sources and translating findings into actionable recommendations
  • Experience with Utilization Management (UM) authorization workflows and prior authorization metrics
  • Expert in SQL for complex exploratory analysis, data modeling, and Extract, Transform, and Load (ETL) processes
  • Advanced proficiency in Tableau (or equivalent BI tools)
  • Strong statistical and analytical skills, including multivariate analyses, regression, and control charts
  • Knowledge of version control (Git, GitHub) and collaborative development workflows
  • Ability to develop and maintain reusable analytic frameworks, templates, and processes
Job Responsibility
Job Responsibility
  • Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights
  • Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance
  • Coordinates with IT and product owners to ensure analytic outputs are integrated into enterprise systems and recurring workflows
  • Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards
  • Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases
  • Maintains awareness of data lineage and governance compliance throughout all analytic work
  • Manages project planning, tracking, and post-implementation assessment for assigned deliverables
  • Mentors and models adherence to analytic development best practices
  • Applies subject matter expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed
  • Perform other duties as assigned
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

Authorization and Claims Analytics Data Analyst III

The Authorization and Claims Analytics Data Analyst III serves as a Subject Matt...
Location
Location
United States , Los Angeles
Salary
Salary:
88854.00 - 142166.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree (or equivalent education/experience)
  • At least 4 years of experience in analytics, with substantial exposure to healthcare operations, managed care, or population health
  • Experience leading end-to-end analytic projects, including requirements gathering, data validation, analysis, and delivery of insights
  • Experience analyzing multiple data sources and translating findings into actionable recommendations
  • Experience with Utilization Management (UM) authorization workflows and prior authorization metrics
  • Expert in SQL for complex exploratory analysis, data modeling, and Extract, Transform, and Load (ETL) processes
  • Advanced proficiency in Tableau (or equivalent BI tools)
  • Strong statistical and analytical skills, including multivariate analyses, regression, and control charts
  • Knowledge of version control (Git, GitHub) and collaborative development workflows
  • Ability to develop and maintain reusable analytic frameworks, templates, and processes
Job Responsibility
Job Responsibility
  • Leads end-to-end analytic development, from structured business case definition and requirements gathering to delivery of validated, actionable insights
  • Conducts advanced analyses evaluating drivers of quality, operational efficiency, and financial performance
  • Coordinates with IT and product owners to ensure analytic outputs are integrated into enterprise systems and recurring workflows
  • Develops, optimizes, and automates analytic assets (data models, dashboards, reports) following enterprise design and refresh standards
  • Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases
  • Maintains awareness of data lineage and governance compliance throughout all analytic work
  • Manages project planning, tracking, and post-implementation assessment for assigned deliverables
  • Mentors and models adherence to analytic development best practices
  • Applies subject matter expertise in evaluating business operations and processes
  • Identifies areas where technical solutions would improve business performance
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right
New

Maths Teacher

Maths Teachers: Wrexham is Calling! Are you a Mathematics expert ready for a fre...
Location
Location
United Kingdom , Wrexham
Salary
Salary:
Not provided
https://www.randstad.com Logo
Randstad
Expiration Date
March 06, 2026
Flip Icon
Requirements
Requirements
  • Qualified Teacher Status- QTS or QTLS
  • A valid Enhanced DBS Certificate (on update service check) OR willingness to get one
  • Have excellent communication and classroom management skills
Job Responsibility
Job Responsibility
  • Teaching a range of Mathematics topics to students in Years 7 through 11
  • Using diverse teaching methods to ensure every student understands the core curriculum
  • Helping pupils prepare for their GCSE exams with targeted support and revision
  • Keeping up-to-date records of student progress through marking and assessment
  • Collaborative working with other staff members to maintain high educational standards
  • Maintaining a respectful and focused classroom environment
What we offer
What we offer
  • Competitive pay rates that value your skills and experience
  • Access to free CPD courses, safeguarding training, and career progression pathways
  • From daily supply to long-term placements
  • A dedicated consultant to map your career
  • A supportive network where you are truly valued
  • Earn £300 in vouchers for referring a friend to our network
Read More
Arrow Right
New

Cover Supervisor

Are you looking for a new career opportunity in Education? Do you want the oppor...
Location
Location
United Kingdom , Wrexham
Salary
Salary:
Not provided
https://www.randstad.com Logo
Randstad
Expiration Date
March 11, 2026
Flip Icon
Requirements
Requirements
  • Bachelor's degree in any subject
  • Previous experience working in Education or similar role
  • Enhanced Child DBS (or willingness to apply)
  • EWC registration (or willingness to apply)
Job Responsibility
Job Responsibility
  • Deliver lessons planned by the class teacher in their absence
  • Ensure that pupils stay focused and motivated during lessons
  • Manage behaviour in line with the school's behaviour management policy
  • Provide additional support with lunch and break duties where needed
  • Report any safeguarding concerns to the ALNCo
What we offer
What we offer
  • Dedicated consultant with experience working in Education working to find the right role for you
  • Welsh Government Commercial Delivery preferred supplied for schools across North Wales
  • Competitive rates of weekly pay
  • Opportunity to work in local schools to find the right environment for you
  • 24/7 on call system
  • 'Refer a Friend' Scheme with the opportunity to earn £300 in Love2Shop vouchers for every successful referral
Read More
Arrow Right
Jobs by Category
Art and Entertainment Jobs Banking Jobs Call Center Jobs Construction Jobs Consulting Jobs Customer Service Jobs Education Jobs Energy Jobs Finance Jobs Gastronomy Jobs Health and Beauty Jobs Hospitality and Tourism Jobs Human Resources Jobs Insurance Jobs IT - Administration Jobs IT - Software Development Jobs Legal Jobs Logistics Jobs Manufacturing Jobs Marketing, Digital Marketing, SEO, SEM Jobs Media Jobs Nursing Jobs Office Administration Jobs Pharmacy Jobs Physical Work Jobs Public Relations Jobs Public Sector Jobs Purchasing Jobs Quality Control Jobs Real Estate Jobs Research and Development Jobs Sales Jobs
Job Positions Jobs by Country
United States Jobs United Kingdom Jobs India Jobs Canada Jobs Australia Jobs Germany Jobs Ireland Jobs Poland Jobs
Company
Blog About Us Contact
Follow Us
Facebook
X (Twitter)
LinkedIn
Instagram
CrawlJobs Group
ITFlashcards AllDevBlogs
© 2026 CrawlJobs Ltd. All Rights Reserved
Terms & Conditions Privacy Policy