Health Care Quality Management Manager

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Job Description

This is a fully remote role. Applicants can reside anywhere in the county but must be comfortable working EST hours Monday-Friday.

Potential for future travel.

Accountable for health care quality projects and initiatives through direction setting and leadership. Assimilates information to proactively develop quality activities aligned with company strategies and values. Links the quality management activities to business goals. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on aspects of the quality program to develop and influence business strategies.

Responsible for management of a variety of quality management and compliance activities including UM state licensure, state and federal regulations, UM letter content development, review of denial and appeal case documentation and letters, ERO/IRO coordination, complaint management, member satisfaction survey analysis, policy development, UM and Care Management accreditation, RFPs, and other quality improvement activities.

Makes business decisions based on the results of research and data analysis. Has responsibility for decision making regarding the design, development, and implementation strategy of quality improvement projects, and initiatives. Forms and leads cross functional teams to assist business units in integrating quality into their strategic and operational plans. Evaluates and prioritizes recommendations for quality improvement to senior management and/or customers. Develops, implements, and evaluates the organization's policies and procedures to meet business needs. Directs/provides enhancements to business processes, policies and infrastructure to improve operational efficiency across the organization. Influences department business owners and leaders to reach solutions to meet the needs of Plan Sponsors, regulators and other customers while meeting departmental objectives. Performs strategic analysis of business performance data to address Plan Sponsor needs. In partnership with business owners, supports design /development of new or enhanced products and services. Translates knowledge of subject and business needs into clear strategic business plans. Serves as a technical, professional and/or business expert that may cross multiple business functions. Perform other duties as may be required.

Required Qualifications

-Active and good standing Registered Nurse license

-5 years managed care experience within healthcare operations and/or quality management.

-3 years of Utilization Management and/or regulatory experience required

- 2 years leadership experience

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.

If you are vaccinated, you are required to have received at least one COVID-19 shot

prior to your first day of employment and to provide proof of your vaccination status within the first 10 days

of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days

of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply

for a reasonable accommodation within the first 10 days

of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications

-Care Management experience: Case management, Disease/Condition management, and/or Wellness/Lifestyle programs.

-Familiarity with state and federal regulations.

-Experience with documentation submission for NCQA or URAC accreditation.

-Quality Management experience

-Ability to multitask and work in a fast paced environment.

-Strong quantitative, qualitative and analytical skills

-Excellent written, oral and presentation skills.

-Demonstrated project management skills.

Education

Bachelor's degree preferred

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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Company info

CVS Health.
Website : https://www.cvshealth.com