Manager ,Healthcare Quality Project Management

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

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 proje