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.
Job Summary
The Analyst Quality Audit Control II OPS will support the team and business by serving as a quality champion through measuring and monitoring the quality and effectiveness of work processes in Plan Set Up that impact customer satisfaction, medical cost management, and operational efficiency.
Additional responsibilities to include but not limited to the following:
- Conducts quality reviews to assess compliance with established policies, procedures, and regulatory requirements, while performing data analysis to identify, monitor, and communicate quality trends and opportunities for improvement.
- Provides technical and subject matter expertise related to policies, procedures, and operational systems and applications.
- Completes Plan Setup Case Installation and Drafting quality audits across Small Group, Middle Market, National, PEO, and P&L segments for all transaction types utilizing systems including FileNet, LGIT, SMART, BPLV, PIPP, Essentials, BTQ, BCRT Tool, e.Pub and LAT.
- Identifies, documents, and communicates audit findings and errors to business partners through the Quality Assurance Database (QAD).
- Conducts 15% error verification reviews each audit cycle to confirm corrective actions have been completed and identified errors have been appropriately addressed by the business area.
- Provides a secondary review of complex audits and audits containing multiple errors to ensure accuracy, consistency, and audit quality.
- Maintains a current understanding of plan setup policies, procedures, and applicable state and federal regulations to ensure accurate audit execution.
- Performs SOX sample walkthroughs and supports external audit activities by providing documentation, process explanations, and audit evidence.
- Partners with business areas to obtain missing source documentation required to complete audit reviews in a timely and accurate manner.
- Identifies knowledge and skill gaps, recommends training opportunities, and advises leadership on process improvements, quality controls, and procedural enhancements.
- Participates in special projects and continuous improvement initiatives designed to strengthen quality outcomes, compliance, and operational effectiveness.
Required Qualifications
- 2 plus years of experience as a Plan Coordination Consultant with successful quality results.
- Strong analytical skills
- Ability to manage multiple priorities
- Commercial Medical and Pharmacy benefits product knowledge.
- Experience with Aetna applications: QuickBase, Excel, CCI, PIPP, BPLV, LAT, e.Policies, e.Pub, LGIT and basic MS Office Excel and Word.
Preferred Qualifications
- Strong problem solving and critical thinking skills
- Excellent verbal and written communication skills
- Ability to work independently in a team environment
- Prior experience in an audit environment that reflects a proven track record or proficiency in the competencies noted.
- Bachelor's Degree
Education
Associates Degree or an equivalent combination of commercial healthcare insurance experience and demonstrated job-related knowledge, skills, and abilities.
We support a hybrid work environment. If selected and you live near a suitable work location, you may be expected to comply with the hybrid work policy. Under the policy, all hires for in-scope populations should be placed into a hybrid or office-based location, working onsite three days a week.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$21.10 - $49.08This 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.
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.
Skills Required
- 2+ years of experience as a Plan Coordination Consultant with successful quality results
- Strong analytical skills
- Ability to manage multiple priorities
- Commercial medical and pharmacy benefits product knowledge
- Experience with Aetna applications and systems (QuickBase, Excel, CCI, PIPP, BPLV, LAT, e.Policies, e.Pub, LGIT, FileNet, SMART, Essentials, BTQ, BCRT Tool) and basic MS Office (Excel, Word)
- Associates Degree or equivalent combination of commercial healthcare insurance experience and job-related knowledge
- Strong problem solving and critical thinking skills
- Excellent verbal and written communication skills
- Ability to work independently in a team environment
- Prior experience in an audit environment
- Bachelor's Degree
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
