Quality Assurance Consultant

2 weeks ago

Austin, United States CVS Health Full time

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.

**Position Summary**

The Quality Assurance Consultant fulfills the company purpose of helping people on their path to better health by driving quality execution of PBM functional area performance. The Consultant will perform some monitoring activities. However, this position requires a higher level of analysis of monitoring results and a consultant will interact and collaborate with internal colleagues and Business Partners to identify opportunities to improve monitoring methodologies, Operations processes, define those new methodologies and collaborate to develop recommended Operations Process changes and perform root cause analysis. The analysis will drive operational process review and revision, continuous improvement and help Operations reduce individual and departmental operational, regulatory, reputational, financial, and legal risk.

The Quality Assurance department is responsible for monitoring the performance of individual business operations within the PBM that support all Government and Commercial market segments (Medicaid, Exchanges, Commercial, Aetna, Appeals, SGM/CRU, Pharmacy Advisor, Medication Therapy Counseling, Aetna Specialty Pre-Certification, and the Health Insurance Marketplace). QA evaluates functional area performance using various techniques, standards, and methodologies to validate compliance with government regulations, patient safety requirements, performance guarantees and internal processes and procedures. The role of QA in the organization is to identify emerging issues, monitor the effectiveness of controls and processes, and assist in developing process controls in partnership with the business to improve outcomes.

The Quality Assurance Consultant evaluates the processes of facilities to determine the proper use of resources and how to streamline general practices to successfully enhance the company's competitive advantage in the industry. Conducts clinical reviews of solution blueprints to validate design and workflow impact to ensure industry-proven best practices are instilled within the company's strategies and end-product offerings. Communicates with external resources to establish partnerships, discuss treatment plans, clarify functional capacity, and assess file direction.

Additional responsibilities include but limited to the following:

- Evaluates the processes of facilities to determine the proper use of resources and how to streamline general practices to successfully enhance the company's competitive advantage in the industry.
- Conducts clinical reviews of solution blueprints to validate design and workflow impact to ensure industry-proven best practices are instilled within the company's strategies and end-product offerings.
- Maintains domain and product functionality expertise by working with the clinical, services, and product teams; while training others in the same capacity.
- Handles the development, completion, and presentation of consulting deliverables and the procedural plan required to meet established customer expectations for assigned clients.
- Communicates with the analytics lead on value analysis and shares results and findings with internal staff and customers as warranted.
- Collaborates with internal resources to determine which pertinent medical documentation is needed to accurately assess file direction.
- Calls key external resources to establish partnerships, discuss treatment plans, clarify functional capacity, and assess file direction.
- Provides coaching of non-medical staff to increase medical knowledge to ensure compliance with the company's regulatory, safety, quality, and confidentiality protocols and standards.
- Operates with flexibility to meet the needs of a rapidly changing environment, while meeting performance standards set for quality and quantity of work.

**Required Qualifications**
- 5 plus years work experience handling prior authorizations or Clinical Operations.
- Experience using Microsoft Suite including (Excel, Outlook, etc.)

**Preferred Qualifications**
- Adept at problem solving and decision making skills
- Ability to manage multiple competing priorities
- Client Care Access (CAS), RxClaim

**Education**

High school diploma or equivalent GED required.

**Pay Range**

The typical pay range for this role is:
$18.

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