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Position Summary

This is a full-time hybrid opportunity with an expectation to be on-site twice a week. Working schedule is Monday-Friday, 8am-5pm (ET) with flexibility to work outside of business hours, as needed. Candidates may reside in any state but must be local to an Aetna office to meet the hybrid on-site expectations. Preferred to live in Plantation, FL or surrounding areas.

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.

Fundamental Components

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

Required Qualifications

• RN with current unrestricted “multi-state privilege” compact license.

• 3+ years of clinical experience required.

• 2+ years of behavioral health experience required.

• 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

• BSN degree preferred

• Florida resident

• Emergency/critical care experience

• Experience working Grievance cases

• Case Management or Utilization Management experience

• Managed care experience

• Medicaid experience

• Behavioral Health experience

• Systems experience: ATV, ASD, GPS, MedCompass, QNXT, Dynamo, HRP, MedHok

• Experience working with Regulatory Agencies

• Critical thinking skills

• Previous experience working in a remote/virtual environment

Education

• Minimum of Associates or Diploma nursing degree required.

Pay Range

The typical pay range for this role is:

$60,522.80 - $129,600.00

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. 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 jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 05/17/2024

We are an equal opportunity and affirmative action employer. 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.