About the role
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
- Rework team hours of operation are Monday through Friday from 6:00 AM - 7:30 PM Central Standard Time (CST)
- Schedule flexibility including nights, weekend, and holiday coverage.
- This is a full time work from home position
Position Summary
Quality Specialist- Medicare D Quality role administers the quality management system to manage the review of clinical processes, documentation, and patient records.
Interprets regulatory requirements from agencies and governing bodies to assist in the development of compliance policies and procedures.
Additional Responsibilities to include but not limited to the following:
- Learning the rework queues for each line of business
- Working rework reports timely
- Researching and troubleshooting failed claims
- Adding and/or editing overrides in RxClaim
- Logging audits and errors accurately and timely
- Ability to identify trends and provide suggestions for process improvement
- Researching and correcting any issues found in the overall process.
- Raising issues to Coverage Determination Clinical Pharmacists and Management team as needed.
- Reading, analyzing, and interpreting general business correspondence, technical procedures, and governmental regulations.
- Solving practical problems and dealing with multiple concrete variables in standardized situations.
- Performing basic mathematical calculations.
- Ensuring all cases are properly closed.
- Ability to interpret a variety of work instructions provided through multiple mediums.
- Ability to anticipate needs and resolve issues with urgency and to meet quality and production standards.
Required Qualifications
- 2 years of Coverage Determination & Appeals experience.
- MHK, RxClaim, and People Safe proficient.
- Meeting quality and productivity metrics in current role.
Preferred Qualifications
- 3 years of Coverage Determination & Appeals experience.
- 1 year of Medicare PART B experience
- MHK, RxClaim, and People Safe proficient.
- Meeting quality and productivity metrics in current role.
Education
High School Diploma or equivalent GED
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$18.50 - $42.35This 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.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Aplyr's read
CVS Health is a healthcare giant blending retail pharmacy with insurance services, ideal for those interested in diverse healthcare roles and innovation.
What's promising
- •CVS Health's integration of pharmacy and insurance offers diverse career paths.
- •Strong focus on healthcare innovation with initiatives like HealthHUB locations.
- •Extensive national presence provides job stability and opportunities for relocation.
What to watch
- •Recent layoffs in certain divisions raise concerns about job security.
- •High-pressure retail environment may lead to employee burnout.
- •Complex organizational structure can slow decision-making processes.
Why CVS Health
- •CVS Health's acquisition of Aetna uniquely positions it in both retail and insurance sectors.
- •HealthHUB stores offer a distinctive model combining retail and healthcare services.
- •CVS Caremark provides a robust platform for pharmacy benefits management.
Aplyr’s read is generated by AI from public sources. Was it useful?
About CVS Health
CVS Health is a healthcare company that provides a range of services including pharmacy benefits management, retail pharmacy, and health insurance services.
