Quality Management Nurse Consultant

Job DescriptionThe QM Nurse Consultant is a work at home role. Experienced HEDIS record review nurse will be responsible for obtaining, reviewing, abstracting, and data entering medical records utilized for HEDIS ® supplemental data processes. Candidate must understand the NCQA HEDIS ® technical specifications for the designated HEDIS ® supplemental data measures, be able to apply understanding of the technical specifications in the process to review, abstract, and data enter supplemental data, collaborate with the health plan HEDIS ® project managers and other health plan departments (which may include but is not limited to member services, provider relations and integrated care management) to achieve the common goal of improving member outcomes, as measured by the HEDIS®/STAR measures. Must be comfortable accessing a variety of EMR systems remotely to obtain and abstract medical record data per specifications. If within the State of Arizona, may need to conduct onsite visits to obtain, review, abstract, and data enter all medical record data for large groups/groups that request an onsite visit. Reviews documentation and abstracts compliant medical record data for entry into supplemental data tool. Typical office working environment with productivity and quality expectations. Professional customer service demeanor a plus as staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information. Commands a comprehensive knowledge of NCQA HEDIS and STARS Measures for both Medicare and Medicaid, with recent experience in the annual HEDIS audit. Staff will work on a variety of electronic tools and must be comfortable with technology and Microsoft Word, Adobe Acrobat, and Windows 10. High level of accuracy and attention to detail are a must for this position. The ideal candidate is self-motivated and comfortable working under tight deadlines. Professional demeanor, good work ethic, and self-motivated Conscientious problem solver, willing to learn, takes personal pride in their work performance/accuracy Proven organizational and time management skills required Excellent verbal communication skills-clear, concise and appropriate required Experience with a variety of EMR systems highly preferred. Computer literacy and demonstrated proficiency is preferred in order to navigate through internal/external computer systems, Adobe, and MS Office Suite applications, including Word and Excel. Telework requires the ability to self-motivated and be a proactive employee. Volume and accuracy expectations will be communicated and are expected to be met. Work requires the ability to read and interpret medical record documentation, both computer-generated and handwritten. Siting at a workstation for extended periods of time typing on the computer. Ability to multi-task, prioritize and effectively adapt to a fast-paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. If within the State of Arizona, must have reliable transportation and be willing and able to drive within assigned geographic area (maximum of 60 miles) about 25-50% of the time.Work Hours: Monday - Friday 8am-5pmRequired Qualifications Active and unrestricted AZ or compact state RN license required 3+ years work related experience in the healthcare industry 3+ years experience reading and interpreting medical records, including handwritten records 3+ years documenting electronically using keyboard and multiple computer screens-- navigating through internal/external computer systems, and MS Office Suite applications, including Word and ExcelCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications 3+ years of Medical Record Review experience with HEDIS-specific measure review is highly preferred. 1+ years Experience with a variety of EMR systems highly preferred.Education-BSN RequiredBusiness OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15