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CVS Health QM Nurse Consultant in Arizona

Job Description

The 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. At Mercy Care, our vision is for our members to live their healthiest lives and achieve their full potential. We’re a local company, serving Arizonans of all ages who are eligible for Medicaid since 1985. We also serve people who are eligible for both Medicaid and Medicare. Mercy Care is sponsored by Dignity Health and Ascension Health and is administered by Aetna, a CVS Health Business. In April 2021 we’re going to begin delivering integrated physical and behavioral health services to children involved with the child welfare system, in a unique partnership with the Arizona Department of Child Safety and their Comprehensive Health Plan. We value diversity, compassion, innovation, collaboration and advocacy. If your values are the same as ours, let’s work together to make a difference and improve the health and wellbeing of Arizona. 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.

Required Qualifications

• RN with current unrestricted state licensure required. If applicant resides in a noncompact state, an active unrestricted RN state licensure in Arizona is required.• Experience reading and interpreting medical records, including handwritten records• 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• 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.• 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)

Preferred Qualifications

• 3+ years of Medical Record Review experience with HEDIS-specific measure review is highly preferred.• Experience with a variety of EMR systems highly preferred.• 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.


• Bachelor’s degree required

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.