CVS Health

RN, Clinical Compliance Specialist

Posted on

February 16, 2025

Job Type

Full-Time

Role Type

Clinical Operations

License

RN

State License

Texas

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Help & Resources

Company Description

Bring your heart to CVS Health. Every 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 Behaviorsā„¢ 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.

Job Description

How will this role have an impact? Signify Health formed internal clinical compliance team and is excited for this role to help develop clinical quality and compliance and ensure our members receive the best possible care. The RN Clinical Compliance Specialist will assist the team with maintaining policies and processes related to clinical compliance. This role will be responsible for daily operations of the Signify HCS clinical compliance program, as well as any ad hoc regulatory research and analysis as needed. This role will also be responsible for conducting, monitoring, and investigating functions related to clinical compliance driven by member compliance, compliance concerns and member amendment requests. This role will report to our Manager, Clinical Compliance.

Requirements

Ethical conduct RN degree required (associate or bachelors) Intermediate Excel experience preferred. 3+ years experience in an health care setting, some experience with clinical coding guidelines preferred Self-motivated who will take the initiative to learn new programs, policies and skills Self-directed, independent performer, able to act independently and manage day to day objectives Ability to work in a fast-paced environment with rapidly changing priorities Demonstrates flexibility and a positive attitude Able to read, analyze and interpret business, professional, technical or governmental documents. Ability to write reports, business correspondence and procedure manuals. Able to effectively present information and respond to questions from managers, customers and the public. Add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals. Compute rate, ratio and percent, and draw and interpret bar graphs. Solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Proficient in Microsoft Suite and Learning Management Systems. Deep knowledge of presentation software. Preferred Qualifications: Prior workflow experience Intermediate Excel experience Education: Associates or Bachelors in Nursing

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Responsibilities

Conduct audits, including collecting, monitoring and analyzing data. Lead clinical compliance investigations, which will require respectful and confidential investigative techniques. Apply clinical knowledge to gather, collate, and interpret data findings and appropriate next steps. Communicate effectively the findings of confidential investigations to appropriate leadership. Support and maintain clinical compliance policies, procedures and processes at direction of manager and or leadership. Collaborate effectively within a team environment, contributing to team goals and supporting team members as needed Provide support to office of CMO and Clinical Success team Research clinical compliance best practices and any regulatory requirements as needed. Review member amendment requests and present findings to the CMO with recommendations for next steps. Other duties as assigned

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