Full-Time

Provider Network Audit Quality Specialist

Posted on 11/4/2024

CVS Pharmacy

CVS Pharmacy

10,001+ employees

Retail pharmacy and healthcare services provider

Healthcare

Compensation Overview

$18.5 - $35.29Hourly

+ Bonus + Commission + Short-term Incentive Program

Junior

Company Historically Provides H1B Sponsorship

Remote in USA

Category
Auditing
Financial Analysis
Accounting
Required Skills
Data Analysis
Requirements
  • 1-2 years work experience in the audit environment that reflects a proven track record or proficiency in the competencies noted.
  • 1-2 years of experience with claims testing, and a working knowledge of PPO’s.
  • High School Diploma or GED.
Responsibilities
  • Conduct standard quality reviews /audits to measure compliance with published policies, procedures, customer and regulatory guidelines
  • Identify and distribute errors to business partners
  • Assist with the day-to-day maintenance and operations of assigned functional unit
  • Perform analysis of data to identify and communicate trends during day to day work
  • May perform or assist with special projects/reviews
  • May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools
  • Subject matter expert on workflows, policies, components of systems and on daily operations and programs
  • Responsible to support targeted quality audit projects. Report results and make recommendations (e.g., training needs, quality controls and procedures)
  • In partnership with business owners, support the design and development of new processes
  • Develop and implement quality programs and initiatives.
  • Participate in the development and validation of master or detail test plans and strategies
  • Analyze and resolve complex claims scenarios within established time frames
  • Resolves problems in a timely and effective manner.
  • Uses designated systems to obtain information. Understands the impact of actions on system primarily used/maintained. Understands relationships of designated systems.
  • Analyzes and verifies system results to ensure accuracy, accountability and financial data integrity.
  • Possesses working knowledge of functions of other units in department
  • Responds to and resolves customer inquiries and complaints (internal as well as external) both verbal and written correspondence within established unit objectives.
  • Analyzes and resolves system error conditions within established unit time frames.
  • Analyzes and recommends solutions to non-standard requests and requirements from plan sponsors and areas within and outside the area.

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their pharmacies offer prescription medications, over-the-counter health products, beauty items, and general merchandise. CVS Health also includes a pharmacy benefits manager that serves over 75 million plan members and a senior pharmacy care business that assists more than one million patients each year. This integrated approach allows CVS Health to deliver affordable health management solutions, improving access to quality care and health outcomes while helping to lower overall healthcare costs. Unlike many competitors, CVS Health combines retail pharmacy services with clinical care and pharmacy benefits management, making it a significant player in the healthcare sector with a goal of supporting individuals on their journey to better health.

Company Stage

N/A

Total Funding

N/A

Headquarters

Woonsocket, Rhode Island

Founded

N/A

Growth & Insights
Headcount

6 month growth

0%

1 year growth

0%

2 year growth

0%
Simplify Jobs

Simplify's Take

What believers are saying

  • The availability of updated flu and COVID-19 vaccines at CVS Pharmacy and MinuteClinic locations nationwide positions the company as a key player in public health initiatives.
  • The Health Zones funding and collaboration with local organizations in Fresno highlight CVS Pharmacy's role in improving community health outcomes.
  • The introduction of a new store brand for snacks, beverages, and groceries could attract a broader customer base and increase in-store sales.

What critics are saying

  • The competitive landscape in the retail pharmacy sector is intense, with major players like Walgreens and Rite Aid posing significant challenges.
  • The expansion into grocery and snack products may dilute CVS Pharmacy's brand identity as a healthcare provider.

What makes CVS Pharmacy unique

  • CVS Pharmacy's integration of digital tools for scheduling vaccinations and accepting walk-ins offers a seamless and convenient experience for customers, setting it apart from competitors.
  • The company's Health Zones initiative, which focuses on community health and access to healthy food, demonstrates a commitment to social responsibility that goes beyond traditional pharmacy services.
  • CVS Pharmacy's recent launch of a new store brand for snacks, beverages, and groceries diversifies its product offerings, making it a one-stop shop for consumers.

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