QM Nurse Consultant

g issues based on multiple clinical policies. 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 internal Aetna departments to obtain additional information. Evaluates documentation/information to determine compliance with clinical policy, regulatory, and accreditation guidelines. Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. 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. Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines. Condenses complex information into a clear and precise clinical picture while working independently. Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.Required Qualifications

• 3-5 years of direct care clinical experience as an RN required.
• Active and unrestricted RN licensure required in candidate's state of residence.
• 2 years' experience with MS Office suite applications including Excel. Strong computer skills utilizing multiple systems and applications at the same time.
• Must have critical thinking skills.

Preferred Qualifications

• Experience with ICD-10, CPT coding
• Experience with QNXT
• Experience with QuickBase.
• Experience with Cotiviti Editing/CXT

Education

• Registered Nurse with compact license
• Associates Degree required, Bachelors preferred

Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$54,095.00 - $155,538.00This 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 peopleWe 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/benefitsWe anticipate the application window for this opening will close on: 01/30/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.