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QM Nurse Consultant

Primary Location: Bismarck, North Dakota
Additional Locations: ND-Bismarck, OH-New Albany, TX-Arlington, TX-Houston
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Description:
Office-based position in one of the following locations: Bismarck-ND, Houston-TX, New Albany-OH, or Arlington-TX. Internals currently working from home may stay working from home.

Responsible for the review and evaluation of clinical information and documentation. 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. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

Fundamental Components:
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. Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information. Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information. Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines. Condenses complex information into a clear and precise clinical picture while working independently. Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Background Experience:
3-5 years of clinical experience requiredManaged Care experience preferred RN with current unrestricted state licensure required.

Additional Job Information:
Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment

Desired Skills:
Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance

Functional Skills:
Clinical / Medical - Clinical claim review & coding, Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Direct patient care (hospital, private practice)

Technology Experience:
Aetna Application - Aetna Total clinical View, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Education:
Nursing - Registered Nurse (RN)

Potential Telework Position:
No

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests

Click To Review Our Benefits (PDF)

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