Quality Management, Nurse Consultant

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.

This is a full-time remote opportunity. Working schedule is Monday through Friday, 8:00 AM -5:00 PM Eastern Standard Time (EST) with flexibility to work outside of business hours, as needed. 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. Applies specialized clinical knowledge to participate in quality improvement efforts to assess and enhance patient care. Collaborates with the healthcare quality team to collect and analyze clinical data, participate in quality reviews, and identify opportunities for process improvement. Provides insights and recommendations to optimize healthcare practices and promote patient safety and satisfaction.

Works Potential Quality of Care cases (Medical), 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. 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. The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems.