Quality Management Nurse Consultant

Job DescriptionThis is a work at home role with the requirement to reside in the state of Virginia.Standard business hours Monday-Friday. Potential for up to 10% of future travel. The QM Nurse Consultant is accountable for promoting cross-functional communication and fostering a compliant workforce between providers and the Health Plan to develop creative solutions and accomplish goals. The ideal candidate serves as a subject matter expert in Healthcare Effectiveness Data and Information Set (HEDIS) improvement work to interact with, educate, and engage providers to improve healthcare outcomes for Virginia Medicaid members, such as increased compliance with EPSDT and preventive care. Responsibilities include establishing, building, and maintaining positive working relationships with providers and their staff by conducting regular contact and serving as a liaison between providers and the Quality Management department. Working closely with provider partners to enhance collaboration between providers and Aetna, advocating for the use of provider tools, online technology, and Health Plan resources. Supporting provider partners with HEDIS gaps in care, data feeds, and remote medical record collection discussions and education. Educating provider practices on appropriate HEDIS measures, medical record documentation guidelines, and HEDIS ICD-10 CPT coding in accordance with state, federal, and NCQA requirements and on general policies and procedures applicable to the delivery of preventive care. Collecting and analyzing provider quality performance data to identify trends and patterns in gaps of care. Strategizing/coaching on opportunities for provider improvement and gap closure. Delivering quality information to internal and external constituents through written and verbal communication. Actively seeking opportunities for process improvement resulting in efficient and effective work streams. Supporting effective medical record capture for HEDIS medical record review and abstraction of supplemental data.Required Qualifications 3+ years of managed care experience 3+ years of experience using Microsoft Excel Current unrestricted Virginia RN license 1+ year of HEDIS experience requiredCOVID 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 Prior provider education or outreach experience Strong communication skills Ability to work independently Previous claims systems experience Previous EMR and/or HIM experienceEducationEducation Associates degree at minimum BSN preferredBusiness 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: 2026-03-07