Description

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.

Position Summary
The Sr Analyst, Clinical Quality is responsible for the review and evaluation of clinical information and documentation. Review's documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.

Fundamental Components

• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Data gathering requires navigation through multiple system applications.
• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Required Qualifications

• 3-5 years of medical record auditing experience
• 2+ years of HEDIS experience

Preferred Qualifications

• Managed care experience

Education

• Bachelor's Degree in health-related field (e.g., Health ed, Wellness, Health Promotion) OR equivalent work experience

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$46,988.00 - $91,800.00

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 11/20/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.