Senior Manager, Medical Policy QA – Rework Remediation

Job not on LinkedIn

🔥 6 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $67.9k - $182.5k / year

⏰ Full Time

🟠 Senior

🔧 QA Engineer (Quality Assurance)

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Manage the day-to-day operations and execution of the Medical Policy quality assurance and remediation program • Oversee reviews of policy coding, implementation accuracy, operational workflows, and policy-related processes • Monitor quality trends and identify emerging defect patterns or operational risks • Track and report quality performance metrics and remediation outcomes • Manage intake, triage, prioritization, assignment, and tracking of Medical Policy defects and quality concerns • Oversee remediation from issue identification through closure validation • Monitor corrective action plans and escalate aging, high-risk, or unresolved issues • Facilitate root cause analysis using 5-Why and other problem-solving techniques • Track corrective and preventive actions and monitor solution effectiveness • Support governance through status reports, dashboards, remediation summaries, documentation, forums, and operational reviews • Collaborate with Medical Policy, Claims Operations, Appeals, Configuration, Clinical Operations, Informatics, Compliance, and Payment Integrity stakeholders • Coordinate cross-functional activities to resolve defects and implement operational improvements • Manage and develop QA Analysts, Remediation Analysts, and other assigned staff • Establish performance expectations, coach and mentor employees, monitor workloads, and foster continuous improvement

🎯 Requirements

• 5+ years of healthcare operations, Medical Policy, quality assurance, audit, compliance, claims, payment integrity, or related experience • 2+ years of leadership or people management experience • Certified Professional Coder (CPC); Certified Coding Specialist (CCS); OR a registered nurse • Experience conducting root cause analysis and corrective action management • Experience managing cross-functional projects and operational initiatives • Strong analytical, problem-solving, and organizational skills • Experience developing reports, dashboards, and performance metrics • Bachelor's Degree in Healthcare Administration, Business Administration, Nursing, or related field or equivalent experience • Lean Six Sigma Green Belt or Black Belt certification preferred • Project Management Professional (PMP) certification preferred • Certified Professional in Healthcare Quality (CPHQ) preferred • Medical Policy implementation or governance experience preferred • Experience supporting Commercial, Medicare, and Medicaid programs preferred • Experience with policy coding, claims adjudication, or configuration processes preferred

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program • Award target in the company’s equity award program • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being