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Position Summary

Manages and influences health care quality projects and initiatives through design, development, and implementation. These activities enable Aetna to improve health care quality products, services, and processes by partnering across business units to meet business needs and accomplish goals.

In this role, you will work on auditing and preparing statements of compliance for NCQA Health Equity (HEA) and Utilization Management (UM) accreditation for all lines of business (Commercial, Exchange, Medicare, and Medicaid). You will be accountable for health care quality projects and initiatives through direction setting and leadership. You will proactively develop quality activities aligned with company strategies and values. You will link the quality management activities to business goals. This position requires that you proactively build strong business relationships, both internally and externally. You will serve as a resource and subject matter expert (SME) on aspects of the quality program to develop and influence business strategies.

Prioritizes and makes recommendations for the design, development, and implementation strategy of quality improvement projects, and initiatives. 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. Develops, implements, and evaluates the organization’s policies and procedures to meet business needs. Translates and delivers business information to internal and external constituents via formal presentations and/or written communications. Develops documentation templates and systems to support QM projects and initiatives. Educates and consults with unit business managers on quality improvement methods (e.g., workflow, data analysis, metrics).

This role will also participate in our UM auditing program and strategy.   You will have responsibility for the review and evaluation of clinical information and documentation as part of the auditing oversight component to this role. You will review documentation and interpret data obtained from clinical records or systems to ensure alignment with accreditation file review requirements. Data gathering requires navigation through multiple system applications. You will evaluate documentation/information to determine compliance with UM accreditation guidelines. You will accurately apply review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. You will report audit or clinical findings to appropriate staff.

Fundamental Componenets

Prioritizes and makes recommendations for the design, development, and implementation strategy of quality improvement projects, and initiatives. 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. Develops, implements, and evaluates the organization’s policies and procedures to meet business needs. Translates and delivers business information to internal and external constituents via formal presentations and/or written communications. Develops documentation templates and systems to support QM projects and initiatives. Educates and consults with

Required Qualifications

• Project management experience
• 5-7+ years clinical and/or managed care experience in the healthcare industry and quality management required
• 2+ years accreditation experience ie. (NCQA, JCAHO or URAC)

Preferred Qualifications

• Strong communication skills with external clients, primarily regulatory and accreditation partners, including problem resolution and escalating project risks.
• One of the following is preferred:
• Independent clinical license or Registered Nurse (RN)
• Master’s degree (LCSW, LISW, LSW, LPC)
• 1+ years of health equity experience
• 1+ years of auditing experience
• 1+ year of Utilization Management experience

Education
Bachelors degree required

Masters degree preferred

Pay Range

The typical pay range for this role is:

$60,300.00 - $132,600.00

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. 
 
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 Benefits | CVS Health

We anticipate the application window for this opening will close on: 01/19/2025

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