Hybrid RN Manager, Delegation Compliance presso CVS Health

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Role Description 

This position is responsible for a range of activities supporting delegated Care Management and Utilization Management functions. These may include, but are not limited to, responsibility for implementation of new delegated functions, including project planning, system readiness, accountability for reporting requirements, hiring, training, and internal/external communication required for launch. The Manager ensures departmental adherence to program standards, ensures the care programs meet compliance requirements and metrics as set by the health plan and CMS, provides initial and ongoing education to staff, and serves as the liaison between OSH and insurance providers, other business partners, vendors and internal stakeholders as required.

Core Responsibilities 

• Oversee compliance for UM and CM to deliver an unmatched patient experience and ensure delegation compliance. 

• Audit individual charts according to QA Audit Protocols to ensure compliance with program responsibilities and best practices 

• Possess knowledge of contractual, accreditation, federal and business requirements for assigned program and ensure compliance with program requirements and develop corrective action plans as needed 

• Establish work procedures and processes that support the company and departmental standards, procedures and strategic directives 

• Establish workflows that meet compliance requirements and align with organization-wide clinical protocols

• Lead the review of policies and procedures, program descriptions, and evaluations; 

• Conduct training for new team members and other internal parties as required 

• Provide statistical and performance feedback, and coaching on a regular basis to each team member in their assigned region 

• Create and maintain a high-quality work environment so team members are motivated to perform at their highest level 

• Provide continual evaluation of processes and procedures. Responsible for suggesting methods to improve area operations, efficiency, and service to both internal and external staff

• Collaborate with other OSH program leaders to implement initiatives in support of integrating delegated services with core OSH care model (e.g. care team, social work, behavioral health, utilization management, patient engagement, central telehealth, etc.) to promote patient outreach and engagement and identify and address patient needs.

• Serve as point of contact for / management of health plan relationships related to delegated care management 

• Oversight of delegated entities and internal operating partners servicing Care Coordination, including management of operational performance and program execution 

• In partnership with Business Intelligence, set, implement and monitor system configuration requirements in accordance with operational and regulatory specifications required for new programs 

• Complete report submissions, including validation where needed 

• Other duties as assigned 

What we’re looking for 

• Bachelor’s in Nursing

• Active RN license within one or more OSH states

• Willingness to obtain cross-state licensure, as needed

• 5+ years of healthcare experience, preferably in a primary care and/or managed care setting 

• 2+ years direct supervisory experience

• Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire

• Knowledge of Medicare/Medicaid and NCQA requirements

• Practical and operational experience in a managed care environment, preferably with working knowledge of related legal/regulatory/health plan requirements 

• Demonstrated experience leading teams, competence with change management, and leading process improvement 

• Knowledge relating to healthcare delivery workflows, project management, and quality improvement is required 

• Prior experience in a similar role at an IPA, Health Plan or MSO will be advantageous 

• Strong teamwork and interpersonal skills. Must be able to work effectively with cross functional groups, fostering teamwork with a commitment to quality 

• Passion for excellence, willing to go the extra mile to achieve objectives and ensure consistently high quality work product 

• Ability to succinctly summarize and synthesize large amounts of information 

• Quick learner comfortable with a high level of ambiguity 

• Strong accountability and discipline against timelines and deliverables 

• Strong clinical and assessment skills

• Outstanding verbal and written communication skills

• Ability to work independently and maintain flexibility in a fast-paced, start-up environment

• Self-starter with a high level of accountability and responsibility for the outcome of care

• Highly organized and able to manage multiple priorities appropriately

• Independent problem-solving skills

• Able to work collaboratively and build enduring relationships with providers, patients and the multidisciplinary team.

• A flexible, positive attitude

• Proficient with Microsoft Office, Google Suite, and healthcare EMRs 

• US work authorization 

• Someone who embodies being “Oaky” 

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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. 
 

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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.