Senior Manager, Medical Policy QA – Rework Remediation

CVS Health

. Manage the day-to-day operations and execution of the Medical Policy quality assurance and remediation program .

Posted 10/15/2026full-timeRemote • Connecticut • United StatesSenior💰 $67,900 - $182,549 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in managing Medical Policy quality assurance programs, including oversight of policy coding, operational workflows, and performance metrics. Proven ability to lead cross-functional teams, conduct root cause analysis, and implement corrective actions in a healthcare operations environment.

Highest-signal resume keywords

Healthcare Operations ManagementRoot Cause AnalysisQuality AssuranceLeadership ExperiencePerformance Metrics Development

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Policy CodingClaims AdjudicationOperational WorkflowsCorrective Action ManagementQuality Performance MetricsRemediation ProcessesData AnalysisProject ManagementLean Six SigmaDashboard Development

Soft Skills

Analytical SkillsProblem-SolvingOrganizational SkillsCoachingMentoring

Tools & Technologies

Status ReportsOperational ReviewsDocumentationDashboards

Certifications & Qualifications

Certified Professional Coder (CPC)Certified Coding Specialist (CCS)Lean Six Sigma Green BeltLean Six Sigma Black BeltProject Management Professional (PMP)Certified Professional in Healthcare Quality (CPHQ)

Industry Keywords

Medical PolicyCompliancePayment IntegrityHealthcare AdministrationCommercial ProgramsMedicareMedicaid

Tech Stack

Tools & technologies

PMP

About the role

Key responsibilities & impact

Manage the day-to-day operations and execution of the Medical Policy quality assurance and remediation program
Oversee reviews of policy coding, implementation accuracy, operational workflows, and policy-related processes
Monitor quality trends and identify emerging defect patterns or operational risks
Track and report quality performance metrics and remediation outcomes
Manage intake, triage, prioritization, assignment, and tracking of Medical Policy defects and quality concerns
Oversee remediation from issue identification through closure validation
Monitor corrective action plans and escalate aging, high-risk, or unresolved issues
Facilitate root cause analysis using 5-Why and other problem-solving techniques
Track corrective and preventive actions and monitor solution effectiveness
Support governance through status reports, dashboards, remediation summaries, documentation, forums, and operational reviews
Collaborate with Medical Policy, Claims Operations, Appeals, Configuration, Clinical Operations, Informatics, Compliance, and Payment Integrity stakeholders
Coordinate cross-functional activities to resolve defects and implement operational improvements
Manage and develop QA Analysts, Remediation Analysts, and other assigned staff
Establish performance expectations, coach and mentor employees, monitor workloads, and foster continuous improvement

Requirements

What you’ll need

5+ years of healthcare operations, Medical Policy, quality assurance, audit, compliance, claims, payment integrity, or related experience
2+ years of leadership or people management experience
Certified Professional Coder (CPC); Certified Coding Specialist (CCS); OR a registered nurse
Experience conducting root cause analysis and corrective action management
Experience managing cross-functional projects and operational initiatives
Strong analytical, problem-solving, and organizational skills
Experience developing reports, dashboards, and performance metrics
Bachelor's Degree in Healthcare Administration, Business Administration, Nursing, or related field or equivalent experience
Lean Six Sigma Green Belt or Black Belt certification preferred
Project Management Professional (PMP) certification preferred
Certified Professional in Healthcare Quality (CPHQ) preferred
Medical Policy implementation or governance experience preferred
Experience supporting Commercial, Medicare, and Medicaid programs preferred
Experience with policy coding, claims adjudication, or configuration processes preferred

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program
Award target in the company’s equity award program
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being