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.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.This role is open to Telework anywhere.Hours for this position are M-F 8a-5p in time zone of residence.Help us elevate our patient care to a whole new level!Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand dually eligible members to change lives in new markets across the country.Position Summary/MissionThe dedication of talented and caring health care professionals drives the delivery of high quality, cost effective products and services. They make it possible for members to get the right health care treatment for their needs – and for Aetna to keep its competitive edge.Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to present to internal and external auditors in line with regulatory and accreditation requirements for members and provider. Requires an RN with unrestricted active license.Fundamental Components & Physical Requirements• Considers all documented system information as well as any additional records/datapresented to develop case file presentations.• Data gathering requires navigation through multiple system applications.• Staff may be required to contact internal Aetna departments to obtain additional information.• Evaluates documentation/information to determine compliance with clinical policy,regulatory and accreditation guidelines.• 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 clinicaldocumentation/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.• Verbally presents case files to internal and/or external auditors• Reports audit findings to appropriate staff or others in order to ensureappropriate outcome and/or follow-up for improvement as indicated.Required Qualifications:• 3+ years of clinical experience as an RN• Active and unrestricted RN licensure in state of residence• 1+ year(s) of managed care experience• 1+ year(s) Dual member case management experience• 1+ year(s) of Case Management Dynamo experienceEducation• RN DiplomaBusiness OverviewAt Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.Clinical Licensure RequiredRegistered NursePay RangeThe typical pay range for this role is:$69,628.00 - $149,400.00This 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.For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefitsWe anticipate the application window for this opening will close on: 07/20/2024Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.