Clinical Quality and Compliance Nurse

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.

Core 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 

What are we looking for?

• 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

• Someone who embodies being Oaky

What does being Oaky look like?

• Radiating positive energy

• Assuming good intentions

• Creating an unmatched patient experience

• Driving clinical excellence

• Taking ownership and delivering results

• Being relentlessly determined

Why Oak Street Health?

Oak Street Health is on a mission to rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient communities, and focused on the quality of care over volume of services. We are an organization on the move! With over 200+ locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.

Oak Street Health 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

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. 

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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

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