At 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.
Position Summary
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 do
- Establish processes (with SOPs), capacity / forecast planning, and tools to execute operational service catalog
- Implement key performance indicators (KPIs) to manage operations
- Maintain 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 delivery
- Oversee and lead operational teams in finance function
- Improve internal processes to demonstrate accuracy and transparency in financial management
- Counsel and mentor team members, provide guidance and support to enhance their skills and professional development.
Required Qualifications
- 10 year’s experience in healthcare industry with experience in price management, optimization or modeling.
- 5+ years directly leading operations teams
- 1+ years’ experience with pharmacy appeal related processes and state regulations, and claims adjudication, including claims adjudication logic
Preferred Qualifications
- Outstanding 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 strategies
- Requires exceptional judgment, discretion and confidentiality
- Excellent leadership skills
- Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal
- Ability to work under tight deadlines
- Strong mathematical problem-solving skills
- Prior PBM Knowledge
- Familiarity with wholesaler invoices
Education
Bachelor’s Degree or equivalent experience required.
Pay Range
The typical pay range for this role is:
$100,000.00 - $231,540.00
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.
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 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.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 01/31/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Top Skills
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners.
Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
