Quality Management, Nurse Consultant

CVS Health

1d•Remote

About The Position

CVS Health is dedicated to building a world of health around every individual, fostering a connected, convenient, and compassionate health experience. The organization values passionate, innovative, accountable colleagues who prioritize safety and quality. This role is integral to the OhioRISE Program, an initiative within Ohio Medicaid aimed at delivering the 'Next Generation' of managed care. OhioRISE focuses on supporting struggling children and their families with serious/complex behavioral health needs, coordinating services among MCOs, vendors, and the Ohio Department of Medicaid. The Quality Management Nurse Consultant is responsible for a range of quality management functions, including monitoring quality of care, critical incident reporting, collaborating on HEDIS measures, developing quality strategies for medically complex populations, tracking program performance, collecting data on training outcomes, participating in performance improvement projects, and assisting with NCQA deliverables.

Requirements

Registered Nurse (RN) with current unrestricted state licensure
3 years of clinical experience
1 year using computer on internal and external programs, data entry and Microsoft office experience
Familiar with Ohio system of care
1 years experience with NCQA Accreditation

Nice To Haves

1 year behavioral health, social work or public health experience
1 year Managed Care experience
1 year HEDIS experience, PQOC, and Critical Incidents
Bachelor's Of Science in Nursing Education
Associate's degree in Nursing

Responsibilities

Potential Quality of Care monitoring
Critical incident reporting
Collaboration and coordination with plan HEDIS teams on OhioRISE specific measure reporting, education, and monitoring
Developing quality strategy and framework for medically complex population
Monitoring and tracking of OhioRISE Program performance measures
Data collection and monitoring of Trauma Informed Care, Adverse Childhood Events, and other required training outcomes
Participation in implementation of OhioRISE specific performance improvement projects
Assistance with OhioRISE related NCQA deliverables including review and evaluation of clinical information and documentation
Develops, updates, and maintains Incident Management System (IMS) training to ensure staff and stakeholders understand incident definitions, reporting expectations, timelines, roles and responsibilities, documentation standards, and prevention planning requirements
Translates regulatory and internal process requirements into clear, accessible learning experiences and practical tools (e.g., facilitator materials, job aids, and knowledge checks), using scenario-based content to reinforce accurate incident identification, health and safety documentation, and high-quality prevention planning
Enter data into the Incident Management System (IMS) and work in partnership with Psychiatric Residential Treatment Facilities, Care Management Entities, and the Ohio Department of Medicaid to respond to inquiries and deliver comprehensive information regarding critical incidents