Senior Manager, Medical Policy QA – Rework Remediation

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Oversee the daily operations and implementation of the Medical Policy quality assurance and remediation program.

• Supervise evaluations of policy coding, accuracy in implementation, operational workflows, and processes related to policy.

• Analyze quality trends and pinpoint emerging defect patterns or operational risks.

• Monitor and report on quality performance metrics and outcomes of remediation efforts.

• Manage the intake, triage, prioritization, assignment, and tracking of Medical Policy defects and quality issues.

• Direct remediation processes from the identification of issues through to the validation of closure.

• Keep an eye on corrective action plans and escalate any aging, high-risk, or unresolved matters.

• Conduct root cause analyses using the 5-Why method and other problem-solving methodologies.

• Track corrective and preventive actions while assessing the effectiveness of solutions.

• Assist governance by providing status reports, dashboards, remediation summaries, documentation, forums, and operational reviews.

• Collaborate with stakeholders from Medical Policy, Claims Operations, Appeals, Configuration, Clinical Operations, Informatics, Compliance, and Payment Integrity.

• Coordinate cross-departmental activities to address defects and implement operational enhancements.

• Lead and develop QA Analysts, Remediation Analysts, and other designated personnel.

• Set performance expectations, mentor and coach team members, oversee workloads, and promote continuous improvement.

⛳️ Requirements

• Minimum of 5 years' experience in healthcare operations, Medical Policy, quality assurance, audit, compliance, claims, payment integrity, or a related field.

• At least 2 years of experience in leadership or people management.

• Certified Professional Coder (CPC); Certified Coding Specialist (CCS); OR a registered nurse designation.

• Proven experience in conducting root cause analyses and managing corrective actions.

• Experience in managing cross-functional projects and operational initiatives.

• Strong skills in analysis, problem-solving, and organization.

• Experience in generating reports, dashboards, and performance metrics.

• Bachelor’s Degree in Healthcare Administration, Business Administration, Nursing, or a related field, or equivalent experience.

• Lean Six Sigma Green Belt or Black Belt certification is preferred.

• Project Management Professional (PMP) certification is preferred.

• Certified Professional in Healthcare Quality (CPHQ) is preferred.

• Experience in Medical Policy implementation or governance is preferred.

• Experience supporting Commercial, Medicare, and Medicaid programs is preferred.

• Familiarity with policy coding, claims adjudication, or configuration processes is preferred.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program.

• Award target in the company’s equity award program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.