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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 Summary

This is a fulltime Quality Management Nurse Consultant position in New Jersey. The working schedule is Monday - Friday, 8am - 5pm EST.

Responsible for the review and evaluation of clinical information and documentation. 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. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

Reviewsdocumentationandevaluatespotentialqualityofcareissues basedonclinicalpoliciesandbenefitdeterminations.Considersall documentedsysteminformationaswellasanyadditionalrecords/data presentedtodevelopadeterminationorrecommendation.Datagathering requiresnavigationthroughmultiplesystemapplications.Staffmaybe requiredtocontacttheprovidersofrecord,vendors,orinternalAetna departmentstoobtainadditionalinformation.Evaluates documentation/information to determine compliance with clinical policy,regulatoryandaccreditationguidelines.Accuratelyappliesreview requirementstoassurecaseisreviewedbyapractitionerwithclinical expertisefortheissueathand.Commandsacomprehensiveknowledgeof complexdelegationarrangements,contracts(memberandprovider),clinical criteria,benefitplanstructure,regulatoryrequirements,companypolicyand otherprocesseswhicharerequiredtosupportthereviewoftheclinical documentation/information.Pro-activelyandconsistentlyappliesthe regulatoryandaccreditationstandardstoassurethatactivitiesare reviewedandprocessedwithinguidelines.Condensescomplexinformation intoaclearandpreciseclinicalpicturewhileworkingindependently.Reports auditorclinicalfindingstoappropriatestafforothersinordertoensure appropriateoutcomeand/orfollow-upforimprovementasindicated.

Required Qualifications

• Active and unrestricted RN license in NJ
• Willing and able to travel 50% of their time to meet with providers in Northern New Jersey. Reliable transportation required; Mileage is reimbursed per our company expense reimbursement policy
• 3+ years of clinical experience
• 2+ years of experience using Microsoft Excel

Preferred Qualifications

• HEDIS experience
• Managed Care experience

Education

• Diploma RN or Associates in Nursing required
• BSN preferred

Pay Range

The typical pay range for this role is:

$72,627.36 - $155,538.24

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.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 12/02/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.