Clinical Services Consultant

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 Quality Assurance Consultant fulfills the company purpose of helping people on their path to better health by driving quality execution of PBM functional area performance.  The Consultant will perform some monitoring activities.  However, this position requires a higher level of analysis of monitoring results and a Consultant will interact and collaborate with internal colleagues and Business Partners to identify opportunities to improve monitoring methodologies, Operations processes, define those new methodologies and collaborate to develop recommended Operations Process changes and perform root cause analysis.  The analysis will drive operational process review and revision, continuous improvement and help Operations reduce individual and departmental operational, regulatory, reputational, financial and legal risk. 

The Quality Assurance department is responsible for monitoring the performance of individual business operations within the PBM that support all Government and Commercial market segments (Medicaid, Exchanges, Commercial, Aetna, Appeals, SGM/CRU, Pharmacy Advisor, Medication Therapy Counseling, Aetna Specialty Pre-Certification and the Health Insurance Marketplace).   QA evaluates functional area performance using various techniques, standards and methodologies to validate compliance with government regulations, patient safety requirements, performance guarantees and internal processes and procedures.    The role of QA in the organization is to identify emerging issues, monitor the effectiveness of controls and processes, and assist in developing process controls in partnership with the business to improve outcomes. 

Required Qualifications Intermediate skills with spreadsheets and databases, including a strong working knowledge of MS Excel, MS Access and/or SQL databases Basic project management skills and experience leading peer team projects using basic project management techniques Demonstrated subject matter expertise in assigned line(s) of business Experience in providing subject matter expertise used to develop business requirements for reporting, data aggregation and analysis tied to business metrics and key performance indicators Demonstrated success dealing with ambiguity or uncertainty and ability to learn on the fly to understand and solve new problems Ability to demonstrate a high level of independent judgment and initiative Ability to communicate effectively, both verbally and in writing, in a manner that is clear, logical and consistent Excellent interpersonal skills, including the ability to interact with and influence peers and QA management Prior role in audit, compliance, data analytics and reporting and experience in Pharmacy Benefits Management (especially Medicaid, Exchanges, Commercial, Aetna, Appeals, SGM/CRU, Pharmacy Advisor, Medication Therapy Counseling, Aetna Specialty Pre-Certification and the Health Insurance Marketplace preferred)

Preferred Qualifications Prior role in audit, compliance, data analytics and reporting and experience in Pharmacy Benefits Management (especially Medicaid, Exchanges, Commercial, Aetna, Appeals, SGM/CRU, Pharmacy Advisor, Medication Therapy Counseling, Aetna Specialty Pre-Certification and the Health Insurance Marketplace preferred)

Education
High School Diploma

Pay Range

The typical pay range for this role is:

$18.50 - $35.29

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 Pu