Quality Management 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.Position SummaryThis is a full time remote position. Hours are Monday through Friday, 8am to5pm in time zone of residenceAs a QM Nurse Consultant you will be responsible for the review and evaluation of clinical information and documentation.

Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims.

Independently coordinates the clinical resolution with clinician/MD support as required within the Special Investigations (SIU) area.

Acts as a resource for customer service and claims processing areas.

Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits.

Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers.

Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations.

Adhere to company policies regarding confidentiality to protect member information.

Required Qualifications

5+ years of clinical experience required

2+ years of experience as a Registered Nurse

Must have active, current and unrestricted RN licensure in state of residence

1+ years of experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews.

Must be willing and able to work Monday through Friday 8:00am - 5:00pm in time zone of residence

Preferred Qualifications

Managed Care experience

Client processing experience

Precertification experience

Clinical Appeals experience

EducationAssociates degree requiredBSN preferredPay RangeThe typical pay range for this role is:$60,522.80 - $129,615.20This 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 Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)We anticipate the application window for this opening will close on: 09/29/2024Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.