Description

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

The Quality Management Nurse (QM Nurse) supports Aetna Better Health of Texas by ensuring compliance with regulatory and accreditation standards while driving healthcare quality initiatives. This role combines clinical expertise with quality improvement leadership, including clinical documentation review, Performance Improvement Projects (PIPs), ANE oversight, and policy development. The QM Nurse collaborates across teams to analyze data, implement interventions, and monitor outcomes for Medicaid programs (STAR, CHIP, STAR Kids). Additional responsibilities include provider education, committee coordination, and strategic reporting to align local efforts with state and national quality goals.

Key Responsibilities

Clinical Review & Compliance

• Review and evaluate clinical documentation for accuracy and compliance with regulatory and accreditation requirements.
• Apply clinical criteria and policies to member/provider claims and coordinate clinical resolutions with MD support.

Performance Improvement Projects (PIPs)

• Design, implement, and evaluate PIPs in alignment with HHSC and EQRO guidance
• Conduct root cause analyses and develop culturally and linguistically appropriate interventions.
• Collaborate with informatics and clinical teams to refine data sets, monitor progress, and adjust interventions.
• Manage PIP data lifecycle, including tracking numerators/denominators, calculating rates, and preparing deliverables for HHSC/EQRO.
• Navigate HHSC submission portal, adapt workflows to meet evolving requirements, and advocate for process improvements.

ANE Oversight

• Manage ANE and Critical Incident reporting process, ensuring compliance with DFPS and internal policies.
• Maintain ANE reporting grids, coordinate with case management, and lead training initiatives for mandatory reporters.
• Submit quarterly ANE reports to the State in collaboration with Informatics.

Policy Development & Peer Support

• Author and revise internal policies and contribute to peer review of others.
• Mentor peers on policy processes and participate in open office hours to improve team engagement.

Provider Communication

• Develop and edit provider education on topics such as social determinants of health, formulary updates, and PIP progress.

Committee Support

• Coordinate committee logistics, including agenda development, binder creation, and role verification.

Data Analysis & Strategic Collaboration

• Partner with analysts for ad hoc data requests and performance tracking
• Support dashboard development and participate in monthly strategy meetings to align local efforts with national quality goals.

Required Qualifications

• 3+ years of clinical experience in a healthcare setting.
• 2+ years as a Registered Nurse (RN) or License Practical Nurse/ License Vocational Nurse.
• Active, current, and unrestricted RN/LVP/LPN license in the state of residence.
• Proficiency in Microsoft Office Suite (Outlook, Excel) and ability to navigate web-based tools, data manipulation and reporting tools.

Preferred Qualifications

• Experience in Healthcare Quality, CPHQ preferred.
• Background in Managed Care.
• Familiarity with claims processing workflows.
• Experience with quality improvement, PIPs, ANE oversight, and policy development.

Education

• Associate's Degree in Nursing required.
• Bachelor of Science in Nursing (BSN) preferred.

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$54,095.00 - $155,538.00

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 12/03/2025

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