QM Nurse Consultant

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.Position SummaryThis is a full-time hybrid opportunity with an expectation to be on-site twice a week. Working schedule is Monday-Friday, 8am-5pm (ET) with flexibility to work outside of business hours, as needed. Candidates may reside in any state but must be local to an Aetna office to meet the hybrid on-site expectations. Preferred to live in Plantation, FL or surrounding areas.This position reports to the Potential Quality of Care (PQOC) nurse investigator team manager. This position is responsible for the review and evaluation of protected clinical information and documentation.The PQOC team reviews 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.Works Potential Quality of Care cases (Medical and Behavioral Health), along with Patient Safety Events across all lines of business (Commercial, Medicare, and Medicaid). Independently coordinates the clinical resolution with internal/external clinician support as required.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 critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.This position 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 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.The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems.Required QualificationsRN with current unrestricted compact license.3+ years of clinical experience required.2+ years of behavioral health experience required.2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)Preferred QualificationsBSN degree preferred.Florida resident.Emergency/critical care experience.Experience working Grievance cases.Case Management or Utilization Management experience.Managed care experience.Medicaid experience.Behavioral Health experience.Systems experience: ATV, ASD, GPS, MedCompass, QNXT, Dynamo, HRP, MedHok.Experience working with Regulatory Agencies.Critical thinking skills.Previous experience working in a remote/virtual environment.EducationMinimum of Associates or Diploma nursing degree required.Pay RangeThe typical pay range for this role is: $60,522.80 - $129,600.00. 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.In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through

ColleagueRelations@CVSHealth.com . If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.

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