RN Manager, Delegation Compliance

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Role Description 

This position is responsible for a range of activities supporting delegated Care Management and Utilization Management functions. These may include, but are not limited to, responsibility for implementation of new delegated functions, including project planning, system readiness, accountability for reporting requirements, hiring, training, and internal/external communication required for launch. The Manager ensures departmental adherence to program standards, ensures the care programs meet compliance requirements and metrics as set by the health plan and CMS, provides initial and ongoing education to staff, and serves as the liaison between OSH and insurance providers, other business partners, vendors and internal stakeholders as required.

Core Responsibilities 

• Oversee compliance for UM and CM to deliver an unmatched patient experience and ensure delegation compliance. 

• Audit individual charts according to QA Audit Protocols to ensure compliance with program responsibilities and best practices 

• Possess knowledge of contractual, accreditation, federal and business requirements for assigned program and ensure compliance with program requirements and develop corrective action plans as needed 

• Establish work procedures and processes that support the company and departmental standards, procedures and strategic directives 

• Establish workflows that meet compliance requirements and align with organization-wide clinical protocols

• Lead the review of policies and procedures, program descriptions, and evaluations; 

• Conduct training for new team members and other internal parties as required 

• Provide statistical and performance feedback, and coaching on a regular basis to each team member in their assigned region 

• Create and maintain a high-quality work environment so team members are motivated to perform at their highest level 

• Provide continual evaluation of processes and procedures. Responsible for suggesting methods to improve area operations, efficiency, and service to both internal and external staff

• Collaborate with other OSH program leaders to implement initiatives in support of integrating delegated services with core OSH care model (e.g. care team, social work, behavioral health, utilization management, patient engagement, central telehealth, etc.) to promote patient outreach and engagement and identify and address patient needs.

• Serve as point of contact for / management of health plan relationships related to delegated care management 

• Oversight of delegated entities and internal operating partners servicing Care Coordination, including management of operational performance and program execution 

• In partnership with Business Intelligence, set, implement and monitor system configuration requirements in accordance with operational and regulatory specifications required for new programs 

• Complete report submissions, including validation where needed 

• Other duties as assigned 

What we’re looking for 

• Bachelor’s in Nursing

• Active RN license within one or more OSH states

• Willingness to obtain cross-state licensure, as needed

• 5+ years of healthcare experience, preferably in a primary care and/or managed care setting 

• 2+ years direct