Senior Plan Builder (Meritain Health)

CVS Health; United States; Remote; USD 46,000 - 92,000; Full time

Job summary

An established industry player is seeking a Senior Plan Builder to enhance healthcare solutions through meticulous plan benefit reviews and systematic setups. This role involves collaborating with clients and internal stakeholders to ensure compliance with state and federal mandates while utilizing analytical skills to translate complex benefits into actionable data. The ideal candidate will thrive in a dynamic environment, demonstrating strong organizational and problem-solving skills. Join a dedicated team committed to making healthcare more accessible and compassionate for all.

Benefits

Affordable medical plan options

401(k) plan with matching contributions

Employee stock purchase plan

Wellness screenings and counseling

Tuition assistance

Flexible work schedules

Paid time off

Family leave

Qualifications

• 1+ year experience in healthcare, specifically in Health Insurance Benefits.
• 1+ year experience in plan build and handling escalations.

Responsibilities

• Provide plan benefit review and systematic setup for claims processing.
• Collaborate with clients on benefit interpretation and compliance.

Skills

Healthcare Experience

Analytical Skills

Communication Skills

Problem-Solving Skills

Organizational Skills

Education

Highschool Diploma or GED

Tools

Salesforce

Job description

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 Senior Plan Builders will provide plan benefit review, interpretation, and systematic setup essential to the processing of our claims adjudication system. Meritain’s proprietary system provides a benefit solution for customized benefit plans. Senior Plan Builders must be able to research and follow through on escalations and urgent requests. They must possess an analytical system coding ability to translate plan benefits into system data coding. The setup must also align for exporting in formats used for online viewing and processing related to Customer Service, Enrollment, Billing and Reporting in support of internal and external partners.

• Provides plan benefit review, interpretation, and systematic setup essential to the processing of our claims adjudication system. The setup must also align for exporting in formats used for online viewing and processing related to Customer Service, Enrollment, Billing and Reporting in support of internal and external partners.
• Ability to utilize Meritain’s proprietary system for analytical coding of detailed customized plans rather than standard offerings.
• Participate and engage in discussion with Clients related to benefit interpretation. Advising on State and Federal Mandates as well as system capabilities.
• Facilitating client facing review of plan setup walking through all benefits to assure alignment of benefit interpretation.
• Consult and advise internal stakeholders on complex benefit administration. Advising on options to minimize manual processing and disruption for the Clients.
• Reviews benefit provisions to ensure compliance with state and federal mandates. Evaluation process may also include assessment of summary plan descriptions and other related documents prepared internally or externally by clients.
• Uses business knowledge and experience to make plan design and processing recommendations when working with Clients.
• Evaluates impact of client requested exceptions and develops reasonable alternatives to satisfy client’s needs while minimizing impact on Meritain’s system and operations; Identifies, communicates and tracks cost sensitive items not included as part of the standard process and highlights them for consideration in the determination of rate adjustments or renewal activity.
• Collaborates on review, analysis, and development of recommendations for the design of complex account and benefit structures based on customers’ objectives and Meritain’s system.
• Executes system setup and mapping of client level benefits to align with industry coding (ICD 10, Place of service, Healthcare Reform, etc.), this is similar to entry level IT programming.
• Solicits and assesses internal and external customer feedback to enhance continuous quality improvement on the implementation process (ie. System tools, resources, etc.)
• Demonstrates Salesforce proficiency and understanding for cross functional communication and executive level status reporting.

Required Qualifications

• 1+ year experience working within healthcare (Health Insurance Benefits and/or Claims experience).
• 1+ year Prior Plan build experience.
• 1+ year experience working with escalations, research, multitasking (will be working on more than one client at a time), and mentoring/training.
• Be highly organized and able to quickly prioritize multiple assignments with high quality results.

Preferred Qualifications

• 5+ years’ experience working with healthcare.
• Should have good communication skills with the ability to express complex concepts in a clear and concise manner.
• Should have a high attention to detail and accuracy while focusing on overall project deliverables.
• Should have the ability to remain flexible yet focused during stressful situations.
• Should possess good analytical and problem-solving skills.
• Ability to research and look beyond the first right answer to find the root of a concern.

Education
Highschool Diploma or GED.

Anticipated Weekly Hours

40

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 Senior Plan Builders will provide plan benefit review, interpretation, and systematic setup essential to the processing of our claims adjudication system. Meritain’s proprietary system provides a benefit solution for customized benefit plans. Senior Plan Builders must be able to research and follow through on escalations and urgent requests. They must possess an analytical system coding ability to translate plan benefits into system data coding. The setup must also align for exporting in formats used for online viewing and processing related to Customer Service, Enrollment, Billing and Reporting in support of internal and external partners.

• Provides plan benefit review, interpretation, and systematic setup essential to the processing of our claims adjudication system. The setup must also align for exporting in formats used for online viewing and processing related to Customer Service, Enrollment, Billing and Reporting in support of internal and external partners.
• Ability to utilize Meritain’s proprietary system for analytical coding of detailed customized plans rather than standard offerings.
• Participate and engage in discussion with Clients related to benefit interpretation. Advising on State and Federal Mandates as well as system capabilities.
• Facilitating client facing review of plan setup walking through all benefits to assure alignment of benefit interpretation.
• Consult and advise internal stakeholders on complex benefit administration. Advising on options to minimize manual processing and disruption for the Clients.
• Reviews benefit provisions to ensure compliance with state and federal mandates. Evaluation process may also include assessment of summary plan descriptions and other related documents prepared internally or externally by clients.
• Uses business knowledge and experience to make plan design and processing recommendations when working with Clients.
• Evaluates impact of client requested exceptions and develops reasonable alternatives to satisfy client’s needs while minimizing impact on Meritain’s system and operations; Identifies, communicates and tracks cost sensitive items not included as part of the standard process and highlights them for consideration in the determination of rate adjustments or renewal activity.
• Collaborates on review, analysis, and development of recommendations for the design of complex account and benefit structures based on customers’ objectives and Meritain’s system.
• Executes system setup and mapping of client level benefits to align with industry coding (ICD 10, Place of service, Healthcare Reform, etc.), this is similar to entry level IT programming.
• Solicits and assesses internal and external customer feedback to enhance continuous quality improvement on the implementation process (ie. System tools, resources, etc.)
• Demonstrates Salesforce proficiency and understanding for cross functional communication and executive level status reporting.

Required Qualifications

• 1+ year experience working within healthcare (Health Insurance Benefits and/or Claims experience).
• 1+ year Prior Plan build experience.
• 1+ year experience working with escalations, research, multitasking (will be working on more than one client at a time), and mentoring/training.
• Be highly organized and able to quickly prioritize multiple assignments with high quality results.

Preferred Qualifications

• 5+ years’ experience working with healthcare.
• Should have good communication skills with the ability to express complex concepts in a clear and concise manner.
• Should have a high attention to detail and accuracy while focusing on overall project deliverables.
• Should have the ability to remain flexible yet focused during stressful situations.
• Should possess good analytical and problem-solving skills.
• Ability to research and look beyond the first right answer to find the root of a concern.

Education
Highschool Diploma or GED.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$46,988.00 - $91,800.00

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.

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: 06/09/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

About the company

At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.