- Salary
- $68k – $183k
- Location
- Work At Home-Connecticut, United States of America
- Workplace
- Remote
- Type
- Full-time
- Department
- Healthcare
- Seniority
- Senior
- Education
- Bachelor
- Closing date
- Today
- Source
- Workday
Description
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
Sr. Manager, Medical Policy Quality Assurance (QA) & Rework Remediation is responsible for managing the day-to-day operations of the Medical Policy quality assurance and remediation program. This role oversees quality reviews, issue intake, defect investigation, root cause analysis, corrective action implementation, remediation tracking, and closure validation activities to ensure the accuracy and integrity of Medical Policy implementation and policy coding.
The Manager works collaboratively with Medical Policy, Clinical Operations, Configuration, Claims, Payment Integrity, Informatics, Compliance, Appeals, and Operational business partners to identify, investigate, remediate, and monitor policy-related defects and quality concerns. The role is accountable for maintaining audit-ready documentation, supporting governance processes, monitoring defect trends, and ensuring remediation activities are completed timely and effectively.
This position serves as the operational leader responsible for executing the Medical Policy QA and remediation workflow and ensuring identified issues are addressed through sustainable corrective and preventive actions.
Quality Assurance Management
- Manage the day-to-day execution of Medical Policy quality assurance activities.
- Oversee ongoing reviews of policy coding, implementation accuracy, operational workflows, and policy-related processes.
- Monitor quality trends and identify emerging defect patterns or operational risks.
- Ensure quality review methodologies and documentation standards are consistently applied.
- Track and report quality performance metrics and remediation outcomes.
- Support process improvement activities based on quality findings and trend analysis.
Rework Remediation Oversight
- Manage the intake, triage, prioritization, assignment, and tracking of Medical Policy defects and quality concerns.
- Ensure suspected issues are appropriately researched and validated prior to defect confirmation.
- Oversee remediation activities from issue identification through closure validation.
- Monitor corrective action plans and ensure assigned owners complete required remediation activities within established timeframes.
- Escalate aging, high-risk, or unresolved issues to leadership for review.
- Validate that remediation efforts adequately address identified root causes.
Root Cause Analysis & Corrective Actions
- Facilitate structured root cause analysis activities using standardized methodologies, including 5-Why and other problem-solving techniques.
- Partner with operational and business stakeholders to identify contributing factors and potential corrective actions.
- Ensure root cause findings are documented and supported by appropriate evidence.
- Track implementation of corrective and preventive actions.
- Monitor effectiveness of implemented solutions to reduce recurrence of issues.
- Identify opportunities for process improvements that improve quality and reduce rework.
Operational Governance Support
- Support Medical Policy governance processes through tracking, reporting, and issue management activities.
- Prepare status reports, dashboards, and remediation summaries for leadership review.
- Maintain documentation supporting remediation activities, corrective actions, and closure validation.
- Participate in governance forums, operational reviews, and quality discussions.
- Ensure remediation activities follow established policies, procedures, and compliance requirement
Cross-Functional Collaboration
- Partner with Medical Policy teams, Claims Operations, Appeals, Configuration, Clinical Operations, Informatics, Compliance, and Payment Integrity stakeholders.
- Facilitate collaboration necessary to investigate, remediate, and monitor identified issues.
- Coordinate activities across multiple operational teams to ensure timely resolution of defects.
- Communicate remediation priorities, issue status, and performance results to stakeholders.
- Support implementation of operational improvements and quality initiatives
People Leadership
- Manage and develop QA Analysts, Remediation Analysts, and other assigned staff.
- Establish clear performance expectations and accountability measures.
- Support employee development through coaching, mentoring, and performance feedback.
- Monitor workloads, resource allocation, and prioritization of remediation activities.
- Foster a culture of quality, accountability, collaboration, and continuous improvement.
Required Qualifications
- 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.
Preferred Qualifications
- Lean Six Sigma Green Belt or Black Belt certification.
- Project Management Professional (PMP) certification.
- Certified Professional in Healthcare Quality (CPHQ).
- Medical Policy implementation or governance experience.
- Experience supporting Commercial, Medicare, and Medicaid programs.
- Experience with policy coding, claims adjudication, or configuration processes.
Education
Pay Range
The typical pay range for this role is:
$67,900.00 - $182,549.00
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. This position also includes an award target in the company’s equity award program.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.