Analyst, Health Care QM

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 Healthcare Quality Management Analyst will be responsible for the end-to-end practitioner appeals process and business immediate termination letters. This will include coordination with Medical Directors, participating Network practitioners as well as appealing practitioners and attorneys, to be in compliance with National Committee for Quality Assurance (NCQA) and state and federal regulatory requirements.

Required Qualifications

-Act as subject matter expert for individual practitioner appeals and immediate termination letters.

-Create and collect all documentation required to meet National Committee for Quality Assurance (NCQA) standards and state and federal regulatory requirements

-Work with health plans, local markets, Medical Directors and legal to ensure all requirements are met, including providing education when necessary

-Prepare appeal binder documentation for review and consideration by the ad-hoc Practitioner Appeals Committee

-Prepare and send immediate termination letters on a weekly basis, with an emphasis on state and federal regulatory requirements regarding appeal language

-Strong ability to organize, track and validate data and process

-Strong communication skills with internal and external customers, which include participating Network practitioners as well as attorneysPreferred Qualifications

-3+ years work related experience in the healthcare industry, credentialing or quality management

-NCQA experience preferred

-Strong computer skills including mastery of MS Excel, Word and Adobe Acrobat

-Credentialing and Recredentialing Data System (CARDS) and PRMS experience preferred

-Strong communication skills with external clients, primarily participating practitioners

-Strong critical thinking skillsEducation
Bachelor's degree requiredPay Range

The typical pay range for this role is:$43,888.00 - $102,081.60This 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 HealthWe anticipate the application window for this opening will close on: 01/17/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.