Quality Management Nurse Consultant (QMNC) - Work From Home

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.

Position Summary

We are excited to offer an opportunity to join the Business Integrity Unit - Commercial, where you will play a crucial role in supporting clinical compliance audits. This role involves auditing clinical cases, conducting investigations, providing training and education, offering ongoing consultation on compliance issues, monitoring adherence to compliance controls, and recommending improvements to enhance both clinical effectiveness and regulatory compliance.

Key Responsibilities:

• Collaborate with the BIU team to foster effective relationships with cross-functional teams, clinical services, regulatory commercial compliance and other relevant parties.
• Partner with clinical business areas to gain a deep understanding of business objectives, ensuring that compliance is maintained while meeting organizational needs.
• Analyzes data, identifies trends, and recommend evidence-based practices to improve clinical outcomes, enhance regulatory compliance and drive continuous improvements in clinical effectiveness.
• Provides training and education to healthcare professionals, staff, and regulatory bodies on quality assurance and compliance-related topics.
• Monitor compliance with clinical policies, regulatory standards, and accreditation guidelines as part of audit parameters.
• Condense complex information into a clear and concise format, ensuring accurate reporting and actionable insights.
• Gather data by navigating multiple systems to collect the necessary information for audits and assessments.
• Communicate audit and clinical findings to relevant cross-functional teams or others to ensure appropriate follow-up actions and improvement.

Required Qualifications

• RN licensure required.
• 3-5 years of Utilization Management (UM) clinical experience required.

Required Skills:

• Strong analytical skills with the ability to utilize root cause analysis while identifying trends to ensure compliance.
• Excellent communication skills for training and educating healthcare professionals, staff and business partners.
• Ability to condense complex information into clear and actionable clinical insights.
• Proficiency in navigating multiple systems to gather and analyze data.
• Demonstrated ability to tackle challenging tasks with a proactive approach to think creatively to find innovative solutions.

Preferred Qualifications

• Ability to work both independently and collaboratively in a team environment.
• Strong problem-solving skills with keen attention to detail.
• Experience with compliance audits in a healthcare setting.
• Familiarity with regulatory policies and accreditation guidelines.
• Willingness to collaborate with others and seek guidance when needed to ensure the best outcomes.

Education

• Bachelor's degree preferred or specialized training in relevant field.

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• 
  Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
  
• 
  No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
  
• 
  Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
  

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/01/2025

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