At Aetna, we’re pioneering a total approach to health and wellness, focusing on the whole person - body, mind, and spirit. Our more than 4,000 nurses are central to turning our member’s health ambitions, big and small, into achievements. Your role will include helping members stay well, manage health conditions, and access the right care at the right time. As you do this, we’ll support you in achieving more in your life and your work.
What makes a successful nurse? Here are the traits we are looking for:
- Problem Solver
- Results Driven
- Technology Savvy
- Detail Oriented
- Good Listener
- Open Minded
- Team Player
Paid Time Off & Disability
QM Nurse Consultant Registered Nurse (RN) - WV MCDPrimary Location: Charleston, West Virginia
Additional Locations: WV-Charleston Apply
- Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines and monitoring/analysis of the EPSDT program.
- 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.
- Proactively 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.
- 3+ years of clinical experience required.
- Must possess good writing skills, data gathering abilities, research and documentation skills.
- Must be able to process complex information into a clear, concise picture while working independently.
- Managed Care experience preferred.
- HEDIS experience preferred.
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.
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way. Required Skills: General Business - Applying Reasoned Judgment, General Business - Turning Data into Information, Leadership - Collaborating for Results Desired Skills: Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Leadership - Driving a Culture of Compliance Functional Skills: Nursing - Quality Management, Quality Management - Quality Management Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Education: Nursing - Registered Nurse (RN) Potential Telework Position: Yes 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.
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