Provider Network Audit Quality Analyst

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.Acts as an Advocate for, and support, the business by serving as a quality champion through measuring and monitoring the quality and effectiveness of work processes in claim processing and/or customer service that impact customer satisfaction, medical cost management, and operational efficiency. Consult and/or work cross functionally to influence and promote change in order to continually deliver quality service to our internal and external customers.Position Summary

• Performs routine quality audits for network operations and claim testing for PPO Network creation.
• Conduct standard quality reviews /audits to measure compliance with published policies, procedures, customer and regulatory guidelines
• Identify and distribute errors to business partners
• Assist with the day-to-day maintenance and operations of assigned functional unit
• Perform analysis of data to identify and communicate trends during day to day work
• May perform or assist with special projects/reviews
• May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools
• Subject matter expert on workflows, policies, components of systems and on daily operations and programs
• Responsible to support targeted quality audit projects. Report results and make recommendations e.g., training needs, quality controls and procedures)
• In partnership with business owners, support the design and development of new processes
• Develop and implement quality programs and initiatives. Participate in the development and validation of master or detail test plans and strategies
• Analyze and resolve complex claims scenarios within established time frames
• Resolves problems in a timely and effective manner.
• Uses designated systems to obtain information. Understands the impact of actions on system primarily used/maintained. Understands relationships of designated systems.
• Analyzes and verifies system results to ensure accuracy, accountability and financial data integrity.
• Possesses working knowledge of functions of other units in department Responds to and resolves customer inquiries and complaints (internal as well as external) both verbal and written correspondence within established unit objectives.
• Analyzes and resolves system error conditions within established unit time frames.
• Analyzes and recommends solutions to non-standard requests and requirements from plan sponsors and areas within and outside the area.
• Monitors, reviews, researches, reconciles and balances designated Aetna system activity.

• 1-2+ years work experience in the audit environment that reflects a proven track record or proficiency in the competencies noted.
• Experience with claims testing, and a working knowledge of PPO's.

• Experience with DG system.

• High school diploma or equivalent.

• 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.