Clinical Quality and Compliance Nurse - UM Educator

CVS Health • Chicago, IL

39d

About The Position

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:The Clinical Quality and Compliance Nurse is part of Oak Street Health's Medical Management team, which includes care management and utilization management programs. This role is responsible for ensuring that internal healthcare practices comply with applicable laws, regulations, and policies. This role requires a deep understanding of clinical compliance requirements and involves conducting audits, providing education to staff, and collaborating with internal and external teams to enhance quality of care and maintain compliance standards. This individual will serve as the clinical subject matter expert for internal, regulatory, and/or payer compliance activities.

Requirements

• Licensed Registered Nurse (RN)
• Bachelor's degree in healthcare administration, nursing, or a related field; Master's degree preferred.
• Minimum of 5 years of experience in utilization management, care management, healthcare operations, compliance auditing or a similar role.
• Proficiency in CMS regulation knowledge and healthcare compliance standards.
• Proficiency in NCQA regulation knowledge and healthcare compliance standards
• Strong understanding of utilization management principles, healthcare regulations, and industry standards.
• Excellent analytical, problem-solving, and decision-making skills.
• Exceptional communication and interpersonal skills, with the ability to collaborate effectively across multidisciplinary teams.
• Proficiency in utilization management software systems, electronic health record systems and Microsoft Office applications.
• Proven organizational and detail orientation skills
• US work authorization

Responsibilities

• Demonstrate comprehensive knowledge of CMS, contractual agreements, accreditation standards, federal and state regulations, and business requirements pertinent to assigned programs, ensuring strict compliance.
• Monitor changes in CMS/NCQA and other state/federal regulations and communicate updates to relevant staff to ensure ongoing compliance.
• Collaborate with operations leaders to devise operational action plans based on compliance findings as necessary.
• Develop and maintain internal audit tools and checklists to facilitate efficient compliance assessments for staff and program audits.
• Serve as clinical subject matter expert for clinical quality and compliance activities
• Provide regular input and feedback on auditing results, trends, and improvement activities.
• Recommend and assist with the implementation of process improvement interventions.
• Collaborate with clinical staff to educate and revise training materials based on audit findings.
• Analyze processes and key performance indicators to evaluate compliance risk, internal control effectiveness, and efficiency improvement opportunities.
• Ensure consistent adherence to HIPAA regulations, professional conduct, and ethical practice.
• Develop Corrective Action Plans (CAPs) and Performance Improvement Plans (PIPs), ensuring adequacy of operational responses and ongoing monitoring.
• Undertake any other job duties as assigned.
• Ability to be licensed in multiple states without restrictions
• Other duties as assigned

Benefits

• Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
• Paid vacation, sick time, and investment/retirement 401K match options
• Health insurance, vision, and dental benefits
• Opportunities for leadership development and continuing education stipends
• New centers and flexible work environments
• Opportunities for high levels of responsibility and rapid advancement
• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Number of Employees: 5,001-10,000 employees