Clinical Quality and Compliance Nurse at CVS Health

Chicago, Illinois, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Licensed Registered Nurse (RN)
Bachelor’s degree in healthcare administration, nursing, or a related field; Master’s degree preferred
Minimum of 5 years of experience in utilization management, care management, healthcare operations, compliance auditing or a similar role
Proficiency in CMS regulation knowledge and healthcare compliance standards
Proficiency in NCQA regulation knowledge and healthcare compliance standards
Strong understanding of utilization management principles, healthcare regulations, and industry standards
Excellent analytical, problem-solving, and decision-making skills
Exceptional communication and interpersonal skills, with the ability to collaborate effectively across multidisciplinary teams
Proficiency in utilization management software systems, electronic health record systems and Microsoft Office applications
Proven organizational and detail orientation skills
US work authorization
Ability to be licensed in multiple states without restrictions

Responsibilities

Demonstrate comprehensive knowledge of CMS, contractual agreements, accreditation standards, federal and state regulations, and business requirements pertinent to assigned programs, ensuring strict compliance
Monitor changes in CMS/NCQA and other state/federal regulations and communicate updates to relevant staff to ensure ongoing compliance
Collaborate with operations leaders to devise operational action plans based on compliance findings as necessary
Develop and maintain internal audit tools and checklists to facilitate efficient compliance assessments for staff and program audits
Serve as clinical subject matter expert for clinical quality and compliance activities
Provide regular input and feedback on auditing results, trends, and improvement activities
Recommend and assist with the implementation of process improvement interventions
Collaborate with clinical staff to educate and revise training materials based on audit findings
Analyze processes and key performance indicators to evaluate compliance risk, internal control effectiveness, and efficiency improvement opportunities
Ensure consistent adherence to HIPAA regulations, professional conduct, and ethical practice
Develop Corrective Action Plans (CAPs) and Performance Improvement Plans (PIPs), ensuring adequacy of operational responses and ongoing monitoring
Undertake any other job duties as assigned

Skills

CMS regulations

NCQA standards

clinical compliance

healthcare auditing

regulatory compliance

quality assurance

utilization management

care management

internal audits

staff education

federal regulations

state regulations

accreditation standards

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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