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Position Summary

This is a full-time remote opportunity. Working schedule is Monday-Friday, 8am-5pm (ET) with flexibility to work outside of business hours, as needed.

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

The PQOC team 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.

• Works Potential Quality of Care cases (Medical), 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 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.

• Accurately applies critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.

• This position 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 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.

• The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems.

Required Qualifications

• Current unrestricted compact RN license
• 3+ years of clinical experience
• 2+ years of acute care experience e.g., hospital setting or ambulatory care including critical care, ICU, ER, Med/Surg, OR
• 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Preferred Qualifications

• Willing and able to obtain additional state licenses upon hire (Paid for by the company)
• Current active RN license in IL
• Experience working Grievance cases
• Case Management or Utilization Management experience
• Managed care experience
• Medicaid experience
• Systems experience: ATV, ASD, GPS, MedCompass, QNXT, Dynamo, HRP, MedHok
• Critical thinking skills
• Previous experience working in a remote/virtual environment

Education

• Minimum of Associates or Diploma in Nursing required
• BSN degree preferred

Pay Range

The typical pay range for this role is:

$60,522.80 - $129,615.20

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: 10/09/2024

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