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Aetna is now a CVS Health Company

Healthcare Quality Management Senior Consultant

Primary Location: Concord, CA
Additional Locations: CA-Aliso Viejo, CA-Concord, CA-Cupertino, CA-Encinitas, CA-Gold River, CA-Patterson, CA-Rancho Cucamonga, CA-Sacramento, CA-Stockton, CA-Walnut Creek

Full time telework opportunity open to candidates located in California.

Accountable for audits and oversight of medical organizations and vendor relationships that perform clinical services on behalf of Aetna. Ensure timely review of audit documents by the appropriate committees. Works with internal staff across multiple departments to identify data sources, processes and activities required to meet regulatory and accreditation requirements or meet the objectives of the QM program. Conducts outreach with complex provider partners to share information to improve health outcomes.

Fundamental Components:
Organize and maintain all documents related to the oversight process. Track customer compliance with timely submission of oversight documents as related to regulatory requirements and policies as well as monitor/track compliance with requirements. This position supports NCQA, CMS, and other regulatory compliance initiatives through compliance oversight. Serves as a resource and subject matter expert on aspects of quality programs and accreditation standards while building a strong collaborative relationship with IPAs and Medical Groups. Support internal constituents and business partners through sharing of QM activities. Support achievement of NCQA Accreditation. Communicate to delegated entities about industry standards, Aetna policies, and best practices to improve overall quality program. Identify and communicate trends. Report results and make recommendations. Support external constituents and industry collaboratives.

Background Experience:
5+ years clinical and/or managed care experience in the healthcare industry or quality management required
5+ years experience in healthcare or managed care quality management
Clinical Licensure Required (RN, LPN, LVN, etx)
Highly skilled computer literacy preferred
Strong attention to detail and critical thinking preferred

Required Skills:
Leadership - Collaborating for Results, Leadership - Creating Accountability, Leadership - Driving a Culture of Compliance

Desired Skills:
General Business - Turning Data into Information, Service - Improving Constituent-Focused Processes

Functional Skills:
Quality Management - FE NCQA accreditation, Quality Management - Quality Management

Technology Experience:
Desktop Tool - Adobe Acrobat Suite v5, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
10 - 25%

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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