Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

The Quality Assurance Consultant fulfills the company purpose of helping people on their path to better health by driving quality execution of PBM functional area performance. The Consultant will perform some monitoring activities. However, this position requires a higher level of analysis of monitoring results and a consultant will interact and collaborate with internal colleagues and Business Partners to identify opportunities to improve monitoring methodologies, Operations processes, define those new methodologies and collaborate to develop recommended Operations Process changes and perform root cause analysis. The analysis will drive operational process review and revision, continuous improvement and help Operations reduce individual and departmental operational, regulatory, reputational, financial, and legal risk.

The Quality Assurance department is responsible for monitoring the performance of individual business operations within the PBM that support all Government and Commercial market segments (Medicaid, Exchanges, Commercial, Aetna, Appeals, SGM/CRU, Pharmacy Advisor, Medication Therapy Counseling, Aetna Specialty Pre-Certification, and the Health Insurance Marketplace). QA evaluates functional area performance using various techniques, standards, and methodologies to validate compliance with government regulations, patient safety requirements, performance guarantees and internal processes and procedures. The role of QA in the organization is to identify emerging issues, monitor the effectiveness of controls and processes, and assist in developing process controls in partnership with the business to improve outcomes.

The Quality Assurance Consultant evaluates the processes of facilities to determine the proper use of resources and how to streamline general practices to successfully enhance the company's competitive advantage in the industry. Conducts clinical reviews of solution blueprints to validate design and workflow impact to ensure industry-proven best practices are instilled within the company's strategies and end-product offerings. Communicates with external resources to establish partnerships, discuss treatment plans, clarify functional capacity, and assess file direction.

Additional responsibilities include but limited to the following:

- Evaluates the processes of facilities to determine the proper use of resources and how to streamline general practices to successfully enhance the company's competitive advantage in the industry.

- Conducts clinical reviews of solution blueprints to validate design and workflow impact to ensure industry-proven best practices are instilled within the company's strategies and end-product offerings.

- Maintains domain and product functionality expertise by working with the clinical, services, and product teams; while training others in the same capacity.

- Handles the development, completion, and presentation of consulting deliverables and the procedural plan required to meet established customer expectations for assigned clients.

- Communicates with the analytics lead on value analysis and shares results and findings with internal staff and customers as warranted.

- Collaborates with internal resources to determine which pertinent medical documentation is needed to accurately assess file direction.

- Calls key external resources to establish partnerships, discuss treatment plans, clarify functional capacity, and assess file direction.

- Provides coaching of non-medical staff to increase medical knowledge to ensure compliance with the company's regulatory, safety, quality, and confidentiality protocols and standards.

- Operates with flexibility to meet the needs of a rapidly changing environment, while meeting performance standards set for quality and quantity of work.

Required Qualifications

- 5 plus years work experience handling prior authorizations or Clinical Operations.

- Experience using Microsoft Suite including (Excel, Outlook, etc.)

Preferred Qualifications

- Adept at problem solving and decision making skills

- Ability to manage multiple competing priorities

- Client Care Access (CAS), RxClaim

Education

High school diploma or equivalent GED required.

Pay Range

The typical pay range for this role is:

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits