Quality Management Nurse Consultant (Field-VA)

CVS Health • Front Royal, VA

5d

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The QM Nurse Consultant is responsible for conducting Quality Management Reviews (QMRs) and supporting Performance Improvement Projects (PIPs) to ensure Medicaid‑funded services meet regulatory, clinical, and quality standards. This role requires strong clinical judgment, audit capability, analytical skills, and the ability to work collaboratively with providers, state agencies, and managed care organizations. Key Responsibilities include: Quality Management Review (QMR) Conduct on‑site and desk audits to ensure services comply with DMAS regulations, Medicaid policy, service limits, medical necessity requirements, and provider qualifications. Review medical records, billing patterns, and service documentation to assess compliance and identify inconsistencies or potential fraud. Analyze utilization trends and exception reports to identify outliers or inappropriate billing practices. Lead provider engagement activities, including documentation requests, exit conferences, and explanation of findings and corrective actions. Prepare accurate audit documentation, summaries, and referrals as needed. Performance Improvement Projects (PIPs) Lead validation and evaluation of PIPs in clinical & non-clinical areas per CMS EQR Protocols 3 & 7. Design and refine study topics, aims, populations, sampling methods, indicators, and data collection plans. Conduct statistical analysis on claims, encounter, and survey data; interpret findings accurately. Guide and support market through PIP planning and implementation with best practices and data-driven interventions. Facilitate stakeholder focus groups and technical assistance sessions. Create comprehensive deliverables: protocols, validation assessments, technical reports, improvement plans, and presentations. Maintain project timelines, coordinate subcontractors, and track deliverables. Additional Quality Operations Support regulatory and accreditation activities such as NCQA, HEDIS, CAHPS and organizational performance improvement strategies. Participate in cross-functional quality activities as assigned.

Requirements

• Licensed Registered Nurse (RN) with an unrestricted Virginia license.
• Virginia residency required.
• Minimum 3+ years’ experience in Medicaid managed care, quality improvement, PIPs, or EQRO-related functions.
• Strong knowledge of Medicaid regulations, DMAS requirements, and CMS EQR Protocols.
• Proficiency in study design, sampling, data analysis, and quality improvement methodologies (e.g., PDSA).
• Excellent communication skills, with experience engaging providers and presenting findings to leadership or stakeholders.
• Strong project management skills and proficiency in Excel, PowerPoint, and data analysis tools.
• Up to 20% travel required.
• Associates or diploma nursing degree required
• Bachelor of Science in Nursing preferred.

Nice To Haves

• Certified Professional in Healthcare Quality (CPHQ) or Project Management Professional (PMP).
• Prior experience with EQRO reviews or state-level Medicaid oversight.
• Experience conducting site visits, facilitating focus groups, or leading training sessions.

Responsibilities

• Conduct on‑site and desk audits to ensure services comply with DMAS regulations, Medicaid policy, service limits, medical necessity requirements, and provider qualifications.
• Review medical records, billing patterns, and service documentation to assess compliance and identify inconsistencies or potential fraud.
• Analyze utilization trends and exception reports to identify outliers or inappropriate billing practices.
• Lead provider engagement activities, including documentation requests, exit conferences, and explanation of findings and corrective actions.
• Prepare accurate audit documentation, summaries, and referrals as needed.
• Lead validation and evaluation of PIPs in clinical & non-clinical areas per CMS EQR Protocols 3 & 7.
• Design and refine study topics, aims, populations, sampling methods, indicators, and data collection plans.
• Conduct statistical analysis on claims, encounter, and survey data; interpret findings accurately.
• Guide and support market through PIP planning and implementation with best practices and data-driven interventions.
• Facilitate stakeholder focus groups and technical assistance sessions.
• Create comprehensive deliverables: protocols, validation assessments, technical reports, improvement plans, and presentations.
• Maintain project timelines, coordinate subcontractors, and track deliverables.
• Support regulatory and accreditation activities such as NCQA, HEDIS, CAHPS and organizational performance improvement strategies.
• Participate in cross-functional quality activities as assigned.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree