Manager, Client Benefits

Job description

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. Position Summary As a Manager, Client Benefits, you will be part of the Client Benefit Services QA team, partnering with Clinical, Benefit, and Technology teams to drive quality, compliance, and operational excellence. Leveraging your PBM expertise, analytical skills, and knowledge of AI enabled solutions, you will analyze complex business processes, interpret Medicaid and Medicare benefit/clinical requirements, and translate them into clear business rules, test strategies, and validation scenarios. You will also identify opportunities to improve efficiency through automation, intelligent testing solutions, and data driven decision making. In this role, you will independently lead day to day clinical and benefit testing initiatives, ensuring accurate and high quality testing outcomes. You will define testing requirements, develop test data and scenarios, execute and validate results, and provide business rules that support automation frameworks. By utilizing AI assisted tools and advanced analytics, you will enhance test design, improve test coverage, streamline documentation, identify potential risks and defects, and deliver actionable insights that improve overall testing effectiveness. You will actively collaborate with internal and external stakeholders, participate in client discussions, and communicate testing results and recommendations to support successful project delivery. To be successful, you will bring a strong combination of leadership, innovation, problem solving, and analytical thinking. You will define enterprise level benefit/clinical testing strategies, mentor and train testing resources, and drive initiatives that ensure benefit accuracy and regulatory compliance across all lines of business. As a subject matter expert, you will leverage automation, AI driven insights, and continuous improvement practices to enhance quality, increase operational efficiency, improve client satisfaction, and serve as a trusted point of contact for reducing quality-related production issues while supporting strategic business objectives. As a Manager, Client Benefits you will be a Subject Matter Expert (SME), and will own following responsibilities: • Serve as the primary SME for testing client benefit plan designs across Formulary and Utilization Management programs, ensuring accurate validation and clear communication of test results to internal teams and external clients. • Analyze client business requirements, regulatory guidelines, and benefit designs, and translate them into effective test scenarios, business rules, and validation strategies. • Utilize PBM tools and platforms such as EZTEST, Salesforce, EZQUERY, Excel Macros, Formulary Management Systems, Benefit Builder, and other testing applications to support benefit validation activities. • Interpret CMS, Medicaid, Medicare, and state specific mandates, converting requirements into testable business rules and validating compliance before production implementation. • Lead and facilitate client and stakeholder meetings, providing testing updates, risk assessments, recommendations, and ensuring benefit configuration accuracy. • Build strong partnerships with clients and cross functional teams by taking a consultative approach to understanding business needs and deliver high quality testing solutions. • Define testing requirements, create test plans and test cases, execute testing, document results, and obtain stakeholder approval to ensure successful project delivery. • Identify project risks, perform impact analysis, and develop mitigation strategies while providing regular status updates to leadership and key stakeholders. • Drive continuous process improvement initiatives by identifying testing inefficiencies, recommending best practices, and supporting team training and development. • Provide guidance and mentorship to testing resources on clinical setup, validation methodologies, compliance requirements, and quality standards. • Support projects through all stages of the testing lifecycle, ensuring issues are resolved, validations are completed, and deliverables meet client expectations. • Identify testing gaps across Commercial, Medicaid, Medicare, and Exchange lines of business and develop comprehensive testing strategies to improve coverage and quality. • Leverage automation, AI enabled testing tools, and advanced analytics to improve testing accuracy, accelerate turnaround times, enhance defect detection, and optimize test coverage. • Explore opportunities to utilize Generative AI for test case generation, requirement analysis, documentation automation, predictive quality insights, and intelligent risk identification. • Use data driven insights and AI assisted analytics to identify trends, improve testing effectiveness, reduce production defect leakage, and support informed decision making. Required Qualifications: • 5+ years of Healthcare/PBM experience with both Benefit and Clinical Testing experience. • PBM and Claim Adjudication experience with a strong understanding of Benefit and Clinical Configuration setup and validation. • Demonstrated experience managing and organizing projects from start to completion. • Experience with Formulary and Utilization Management. • Expertise in EZTest, EZQuery/SQL, and other PBM testing tools. • Experience training, mentoring, and supporting resources on Clinical and Benefit Testing processes. • Experience with test automation and AI enabled tools to improve test coverage, streamline documentation, and increase testing efficiency. Preferred Qualifi