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Nurse Careers

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.

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Success Profile

What makes a successful nurse? Here are the traits we are looking for:

  • Collaborative
  • Deadline-oriented
  • Organized
  • Problem Solver
  • Results Driven
  • Technology Savvy
  • Adaptable
  • Compassionate
  • Detail Oriented
  • Flexible
  • Good Listener
  • Open Minded
  • Responsible
  • Team Player

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Benefits

  • Health

  • Wellness

  • Financial

  • Paid Time Off & Disability

  • Life Insurance

  • Additional Benefits

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Job Details

QM Nurse Consultant - RN (Registered Nurse)

Primary Location: Chicago, Illinois
Additional Locations: IL-Chicago
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Description:
The QM Nurse Consultant is responsible for the review and evaluation of clinical information and documentation specifically Potential Quality of Care cases. 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:
Required:
- 3+ years of clinical experience
- RN with current unrestricted state licensure

Preferred:
- Managed Care experience

Additional Job Information:
The Quality Management Department has a working environment with productivity and quality expectations. The work on the Potential Quality of Care team requires the ability to perform close inspection of hand written and computer generated documents, collaboration with our Medical Directors, presentations to our oversight committee, as well as supporting the teams workload. Position requires ability to prioritize and effectively adapt to a fast paced changing environment, proficiency with computer skills which includes navigating multiple systems, and effective communication skills, both verbal and written.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts

Desired Skills:
General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen

Functional Skills:
Clinical / Medical - Quality management

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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