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Quality Management Nurse Consultant

Primary Location: Blue Bell, Pennsylvania
Additional Locations: PA-Blue Bell
The QM Nurse Consultant is responsible for the quality oversight of the Territorial and Specialty Clinical Programs. The QM Nurse Consultant will review and evaluate clinical information and ensure documentation, integration points, and technology is utilized appropriately. The quality reviewer will review documentation and interpret data obtained from clinical records or systems to apply case management processes, appropriate clinical criteria and policies that are in line with regulatory and accreditation requirements for our members; requires an RN with an unrestricted active license with certification in CM preferred (CCM).

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:
RN licensure required
3+ years clinical experience required
1+ years case management experience required

Quality or auditing experience preferred
Managed care experience preferred
CCM preferred

Additional Job Information:
Thisis an exciting time to join the quality team to support the Territorial andSpecialty Clinical Programs. We are inspired to make a difference, and we arecommitted to integrity and clinical excellence. We strive to work together as ateam to enhance the quality of services rendered by our staff.
· 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, Technology - Leveraging Technology

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results

Functional Skills:
Nursing - Case Management, Nursing - Concurrent Review/discharge planning, Nursing - Medical-Surgical Care

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Healthcare Management - Certified Professional in HealthCare Quality, Nursing - Certified Case Manager (CCM), Nursing - Registered Nurse

Potential Telework Position:

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 for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)


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