Potential Quality of Care (PQOC) Quality Management Behavioral Health Nurse Consultant - Remote

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

This position reports to the Potential Quality of Care (PQOC) nurse investigator team manager. This position is responsible for the review and evaluation of Behavioral Health (BH) protected clinical information and documentation.
 

The PQOC team reviews quality of care concerns by reviewing 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. This position commands a comprehensive knowledge and experience working in BH inpatient and outpatient settings.

Additional responsibilities to include but not limited to the following:

• Works BH Potential Quality of Care cases, 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 BH 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.
• 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.
• Collaboration with BH Medical Directors, Network, Legal, Risk Management, etc.
• The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems.

Required Qualifications

• Candidate must have active and unrestricted Registered Nurse (RN) License in the state of residence and willing to obtain additional licensure as needed
• 2+ years of behavioral health inpatient or outpatient experience

Preferred Qualifications

• Compact Registered Nurse (RN) License
• Case Management or Utilization Management experience
• Managed care experience
• Medicaid experience
• Systems experience: ATV, GPS, MedCompass, QNXT, Dynamo, MedHok
• Previous experience working in a remote/virtual environment
• Preference for those in EST or CST zones.

Education

• Associate's Degree in Nursing or Nursing Diploma (REQUIRED)
• Bachelor's of Science in Nursing (PREFERRED)

License

• Active and unrestricted Registered Nurse (RN) License in the state of residence and willing to obtain additional licensure as needed

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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