Quality Management Nurse Consultant

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.

• 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.

• 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.

• 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.

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

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

• 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.

• 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.

• 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.

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

• 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.