Manager, Pharmacy Adjudication & Affordability

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, 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.

Summary CVS Health is on a mission to transform healthcare by making it more accessible, affordable, and easier to navigate for the patients we serve. As a critical part of this effort, the company is reimagining how prescriptions are processed, priced, and delivered—leveraging its scale, clinical expertise, and 10,000‑store footprint to improve patient outcomes and reduce cost-related barriers to care. The Manager, Adjudication & Affordability plays a pivotal role in translating affordability strategies into real-world prescription processing outcomes. This role sits at the intersection of pharmacy adjudication, patient access, and benefit optimization—leveraging deep expertise in Coordination of Benefits (COB) sequencing, NCPDP standards, and plan design to ensure patients receive the most affordable and appropriate medication pathway available. This Manager will be responsible for designing, executing, and continuously improving adjudication logic and plan sequencing strategies that maximize patient benefits, dynamically adjust for cost drivers, and enable scalable affordability solutions across the CVS ecosystem. The role requires strong analytical rigor and hands-on execution, including active involvement in configuration validation, UAT, and post-launch optimization. Working cross-functionally with Trade, Growth, Payer Relations, IT, Digital, and Pharmacy Operations, this individual will help shape and operationalize innovative affordability solutions—from early-stage ideation through implementation—ensuring they are technically feasible, compliant, and impactful for patients. The ideal candidate brings a deep understanding of pharmacy adjudication and benefit structures, strong problem-solving capability, and the ability to translate complex scenarios into actionable insights. This role demands a highly collaborative operator who can navigate ambiguity, influence partners, and deliver measurable improvements in patient affordability, claim success, and overall pharmacy experience.

Plan Sequencing Strategy, Adjudication Design, and Affordability Enablement Serve as a subject matter expert in prescription adjudication, with deep expertise in: Coordination of Benefits (COB) sequencing rules NCPDP standards and transaction logic Plan design constraints across PBM, retail, and third-party affordability programs Design, configure, and optimize complex plan sequencing strategies that: Maximize utilization of patient benefits Adjust dynamically based on patient profile, treatment type, and out-of-pocket cost Enable the lowest appropriate cost outcome while maintaining compliance Partner with senior leadership to translate affordability strategies into executable adjudication logic and workflows. Support the development of curated affordability journeys by ensuring adjudication pathways: Reflect real-world patient scenarios (insured, underinsured, uninsured) Enable effective routing across benefits, coupons, discount cards, and cash options Continuously evaluate and refine sequencing rules based on: Claims performance and reject patterns Patient cost outcomes and abandonment signals Evolving payer rules and market dynamics Affordability Analytics & Insights Identify, quantify, and prioritize patient affordability opportunities using pharmacy claims and performance data to reduce out-of-pocket costs and cost-related abandonment. Develop and maintain analytics, reporting, and diagnostic frameworks to monitor: Claim success and reject trends