Quality Specialist - Medicare D Quality

Schedule 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 The 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 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 Employment Details Anticipated Weekly Hours: 40 Time Type: Full time Pay Range: The typical pay range for this role is: $18.50 - $42.35. 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. Benefits This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Equal Opportunity Statement CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran --- committed to diversity in the workplace. #J-18808-Ljbffr