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.

Candidate must reside in the EST or CST

Business Compliance Manager, NCQA Accreditation

• Develop tactical and operational plans to achieve the Business Compliance area's goals, and communicates plans to managers, supervisors, and teammates ensuring compliance with all relevant laws and regulations.

• Assist with the development of compliance policies and procedures to ensure safe and lawful operations.

• Determine and implement solutions to address compliance gaps and communicates with senior managers and executives to ensure regulations are followed concisely.

• Ensure adherence to applicable laws, regulations, and NCQA accreditation standards by implementing compliance training programs and conducting internal audits to identify potential compliance issues.

• Support Department of Insurance inquiries and external compliance audits relating to delegated oversight and management functions of medical management programs.

• Identify areas for improvement within healthcare processes, systems, and operations, and works with clinicians and cross-functional teams to develop and implement quality improvement initiatives that drive change.

• Ensure healthcare quality standards and regulations are met by monitoring and evaluating the performance of healthcare services, programs, and processes.

• Integrate quality improvement initiatives that align with organizational objectives and support broader company healthcare strategies. Contribute to the successful execution of quality improvement initiatives and work towards promoting excellence in our medical management programs.

• Participates in committees and workgroups focused on healthcare quality and process improvement methodologies.

Required Qualifications

• A minimum of 5 years’ experience in a regulatory compliance position in healthcare insurance

• A minimum of 3 years’ experience of end-to-end management of NCQA accreditation and reaccreditation.

• Experience supporting medical management programs - Utilization Management and Case Management specifically.

• Demonstrated working knowledge of Federal laws concerning health care and health insurance law including federal healthcare reform, HIPAA, ERISA, DOL, and federal mental health parity.

• Demonstrated working knowledge of state insurance laws, and the relationship between state and federal laws.

• Have or able to quickly develop an understanding of Aetna / American Health Holding products and services.

• Proficiency with the use of a variety of software applications (MS Project, Word, Excel, and PowerPoint).

• Excellent communication and interpersonal skills.

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Preferred Qualifications

• Project management experience.

• Total Quality Management (TQM) experience.

Education

• Bachelor's degree preferred or equivalent professional work experience.

Pay Range

The typical pay range for this role is:

$54,300.00 - $159,120.00

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.

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 Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 01/25/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.