[Hiring] Quality Management Behavioral Health Nurse Consultant @CVS Health

Role Description

This position reports to the Potential Quality of Care (PQOC) nurse investigator team manager. This position is responsible for the review and evaluation of Behavioral Health (BH) protected clinical information and documentation.

• The PQOC team reviews quality of care concerns by reviewing 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.
• This position commands a comprehensive knowledge and experience working in BH inpatient and outpatient settings.
• Works BH Potential Quality of Care cases, 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 BH 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.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Reports clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.
• Collaboration with BH Medical Directors, Network, Legal, Risk Management, etc.
• The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems.

Qualifications

• Candidate must have active and unrestricted Registered Nurse (RN) License in the state of residence and willing to obtain additional licensure as needed.
• 2+ years of behavioral health inpatient or outpatient experience.

Requirements

• Compact Registered Nurse (RN) License.
• Case Management or Utilization Management experience.
• Managed care experience.
• Medicaid experience.
• Systems experience: ATV, GPS, MedCompass, QNXT, Dynamo, MedHok.
• Previous experience working in a remote/virtual environment.
• Preference for those in EST or CST zones.

Education

• Associate's Degree in Nursing or Nursing Diploma (REQUIRED).
• Bachelor's of Science in Nursing (PREFERRED).

License

• Active and unrestricted Registered Nurse (RN) License in the state of residence and willing to obtain additional licensure as needed.

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range

The typical pay range for this role is: $60,522.00 - $129,615.00. 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.

Benefits

• 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.