Quality Specialist - Medicare D Quality

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. - Rework team hours of operation are Monday through Friday from 6:00 AM - 7:30 PM Central Standard Time (CST) - Schedule flexibility including nights, weekend, and holiday coverage. - This is a full time work from home position Position Summary Quality Specialist- Medicare D Quality role administers the quality management system to manage the review of clinical processes, documentation, and patient records. Interprets regulatory requirements from agencies and governing bodies to assist in the development of compliance policies and procedures. Additional Responsibilities to include but not limited to the following: - Learning the rework queues for each line of business - Working rework reports timely - Researching and troubleshooting failed claims - Adding and/or editing overrides in RxClaim - Logging audits and errors accurately and timely - Ability to identify trends and provide suggestions for process improvement - Researching and correcting any issues found in the overall process. - Raising issues to Coverage Determination Clinical Pharmacists and Management team as needed. - Reading, analyzing, and interpreting general business correspondence, technical procedures, and governmental regulations. - Solving practical problems and dealing with multiple concrete variables in standardized situations. - Performing basic mathematical calculations. - Ensuring all cases are properly closed. - Ability to interpret a variety of work instructions provided through multiple mediums. - Ability to anticipate needs and resolve issues with urgency and to meet quality and production standards. Required Qualifications - 2 years of Coverage Determination & Appeals experience. - MHK, RxClaim, and People Safe proficient. - Meeting quality and productivity metrics in current role. Preferred Qualifications - 3 years of Coverage Determination & Appeals experience. - 1 year of Medicare PART B experience - MHK, RxClaim, and People Safe proficient. - Meeting quality and productivity metrics in current role. Education High School Diploma or equivalent GED Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $18.50 - $42.35 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 06/17/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply To This Job