Senior Manager Medical Policy QA & Rework Remediation

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

• Manage the day-to-day execution of Medical Policy quality assurance activities.
• Oversee ongoing reviews of policy coding, implementation accuracy, operational workflows, and policy-related processes.
• Monitor quality trends and identify emerging defect patterns or operational risks.
• Ensure quality review methodologies and documentation standards are consistently applied.
• Track and report quality performance metrics and remediation outcomes.
• Support process improvement activities based on quality findings and trend analysis.

• Manage the intake, triage, prioritization, assignment, and tracking of Medical Policy defects and quality concerns.
• Ensure suspected issues are appropriately researched and validated prior to defect confirmation.
• Oversee remediation activities from issue identification through closure validation.
• Monitor corrective action plans and ensure assigned owners complete required remediation activities within established timeframes.
• Escalate aging, high-risk, or unresolved issues to leadership for review.
• Validate that remediation efforts adequately address identified root causes.

• Facilitate structured root cause analysis activities using standardized methodologies, including 5-Why and other problem-solving techniques.
• Partner with operational and business stakeholders to identify contributing factors and potential corrective actions.
• Ensure root cause findings are documented and supported by appropriate evidence.
• Track implementation of corrective and preventive actions.
• Monitor effectiveness of implemented solutions to reduce recurrence of issues.
• Identify opportunities for process improvements that improve quality and reduce rework.

• Support Medical Policy governance processes through tracking, reporting, and issue management activities.
• Prepare status reports, dashboards, and remediation summaries for leadership review.
• Maintain documentation supporting remediation activities, corrective actions, and closure validation.
• Participate in governance forums, operational reviews, and quality discussions.
• Ensure remediation activities follow established policies, procedures, and compliance requirement

• Partner with Medical Policy teams, Claims Operations, Appeals, Configuration, Clinical Operations, Informatics, Compliance, and Payment Integrity stakeholders.
• Facilitate collaboration necessary to investigate, remediate, and monitor identified issues.
• Coordinate activities across multiple operational teams to ensure timely resolution of defects.
• Communicate remediation priorities, issue status, and performance results to stakeholders.
• Support implementation of operational improvements and quality initiatives

• Manage and develop QA Analysts, Remediation Analysts, and other assigned staff.
• Establish clear performance expectations and accountability measures.
• Support employee development through coaching, mentoring, and performance feedback.
• Monitor workloads, resource allocation, and prioritization of remediation activities.
• Foster a culture of quality, accountability, collaboration, and continuous improvement.

The typical pay range for this role is: