Quality Management Nurse Consultant

Hispanic Alliance for Career Enhancement; Dover (DE); Remote; USD 54,000 - 143,000; Full time

Job summary

An established industry player in health solutions is seeking a Quality Management Nurse Consultant to join their remote team. This role involves reviewing clinical documentation related to outpatient therapy services and applying clinical criteria in line with regulatory requirements. With a focus on compassionate care, the company values dedicated professionals who are passionate about transforming health care. You'll enjoy a collaborative environment while contributing to improving patient outcomes. This position offers competitive pay, comprehensive benefits, and opportunities for professional growth, making it an exciting opportunity for RNs looking to make a difference in the healthcare landscape.

Benefits

Affordable medical plan options

401(k) plan with company matching

Employee stock purchase plan

Wellness screenings

Tobacco cessation programs

Weight management programs

Confidential counseling

Financial coaching

Tuition assistance

Flexible work schedules

Qualifications

• 2+ years of clinical experience as an RN required.
• Active RN licensure in the state of residence needed.

Responsibilities

• Review and evaluate clinical information related to outpatient therapy services.
• Coordinate clinical resolutions with clinician/MD support as needed.

Skills

Clinical experience as an RN

Microsoft Office (Teams, Outlook, Excel)

Internet Explorer and Google Chrome usage

Education

Associate's degree in Nursing or Diploma RN

BSN preferred

Tools

MedCompass

CEC

IOP

Job description

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

This is a fully remote Quality Management Nurse Consultant opportunity. The schedule is Monday - Friday, 8am-5pm in the time zone where the candidate resides.

Responsible for the review and evaluation of clinical information and documentation related to outpatient therapy services. 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. Acts as a resource for customer service and claims processing areas.

Required Qualifications

• 2+ years of clinical experience as an RN
• Active unrestricted RN licensure in the state of residence
• Experience using Microsoft Office products, including Teams, Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews

Preferred Qualifications

• Experience with MedCompass, CEC, IOP, or clinical review experience with therapy review types
• Experience working with adults and/or pediatrics outpatient therapy, i.e. occupational therapy, physical therapy, speech therapy, chiropractic, or acupuncture
• Experience working in a multidisciplinary team

Education

• Minimum of an Associate's degree in Nursing or Diploma RN
• BSN preferred

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$54,095.00 - $142,576.00

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: 05/09/2025

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