Manager, Business Compliance

NCQA Accreditation Auditor

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. Preference given to Eastern and Central time zones.

Job Summary

The NCQA Accreditation Auditor is responsible for evaluating healthcare organizations' compliance with NCQA Accreditation standards and supporting quality activities. This role involves conducting audits, preparing documentation, and collaborating with internal teams, as well as external customers to ensure readiness for NCQA accreditation reviews. The auditor plays a critical role in maintaining quality standards and regulatory compliance across managed care operations.

Key Responsibilities

Lead and support monthly NCQA accreditation audits, pre-delegation evaluations, and readiness assessments. Manage file universe reports and prepare multi-specialty case files (mock and regular). Assist the Lead NCQA Manager in evaluating organizational policies, procedures, and practices against NCQA standards. Support all accreditation activities, including URAC and NCQA. Prepare and present audit findings and compliance reports to leadership. Collaborate with cross-functional teams to implement process improvement initiatives. Participate in Clinical Committees and support clinical legislative / regulatory reviews to assess NCQA accreditation impact. Manage timelines and deliverables for client audits. Maintain current knowledge of NCQA standards, regulatory requirements, and industry best practices. Support analysis of reporting and quality improvement opportunities; collaborate on action plans and outcomes. Capture data and analytics, develop reports, and work with subject matter experts to ensure ongoing alignment with NCQA requirements and readiness for future accreditation surveys.

Minimum Requirements

57 years of regulatory and / or clinical audit experience. Experience in medical management, including Utilization Management (UM) and Case Management (CM). Strong understanding of healthcare quality, accreditation processes, and NCQA standards. Licensed clinical professional (RN preferred). Excellent analytical, organizational, and communication skills. Proficiency in audit documentation and reporting tools. Ability to work independently and collaboratively in a team environment. Strong problem-solving and decision-making skills. Proven ability to plan, execute, and deliver on complex projects.

Preferred Requirements

Ability to work independently and collaboratively in a team environment. Strong problem-solving and decision-making skills. Proven ability to plan, execute, and deliver on complex projects.

Education

Bachelor's degree preferred or equivalent experience. Licensed clinical professional required (RN preferred). Specialized training, certification(s), or relevant professional qualification(s).

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is : $54,300.00 - $159,120.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Great Benefits for Great People

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include : 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.