Senior Manager Health Care Quality Management

Job DescriptionAccountable for Commercial and Medicaid NCQA Accreditation quality projects and initiatives through design, development, and implementation. Assimilates information to proactively develop quality activities aligned with company strategies and values. Links quality management activities to business goals. Proactively builds strong business relationships with internal and external business partners. Serves as subject matter expert on all aspects of the quality program.Makes business decisions based on results of research and data analysis. Proven experience as a subject matter expert on NCQA accreditation standards, analysis, Case Management/ Utilization Management file reviews, and supporting quality functions. Leads cross functional teams to assist business units with quality activities. Manages, directs, and plans multiple complex accreditation projects through completion of business objectives. Designs and develops templates, materials, and guidance documentation. Influences change or enhancements to policies and processes to improve quality. Develops and participates in presentation and consulting to business partners on clinical accreditation requirements around Population Health, Care Management, Utilization Management, Pharmacy to achieve results.Required QualificationsMakes business decisions based on the results of research and data analysis.Has responsibility for decision making regarding the design, development, and implementation strategy of quality improvement projects, and initiatives.May manage a QM functional department includingdevelopment and oversight of performance metrics andapplication of HR policies and procedures. Forms and leads cross functional teams to assist business units in integrating quality into their strategic and operational plans.Evaluates and prioritizes recommendations for qualityimprovement to senior management and/or customers.Partners with sales and marketing across all segments intheir efforts to acquire and retain customers (e.g.responding to RFPs), quality presentations, request formeasurement information.Develops and implements the infrastructure of the QM program and Patient Safety strategy.Develops, implements, and evaluates the organization's policies and procedures to meet business needs. Directs/provides enhancements to businessprocesses, policies and infrastructure to improveoperational efficiency across the fluences department business owners and leaders to reach solutions to meet the needs of Plan Sponsors, regulators and other customers while meeting departmental objectives.Performs strategic analysis of business performance data to address Plan Sponsor partnership with business owners, supports design /development of new or enhanced products and services. Translates knowledge of subject and business needs into clear strategic business plans.Serves as a technical, professional and/or business expert that may cross multiple business functions.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications6+years progressive experience in operational quality management roles in the healthcare industry, regulatory environment, NCQA accreditation and/or quality management.Masters degree preferred.Certified Professional in Health Quality (CPHQ) or other certification a plus.EducationBachelor's degree, Nursing degree, or other comparablehealthcare experience.Business OverviewBring your heart to CVS HealthEvery 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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-01