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Quality Management Auditor

Primary Location: Concord, CA
Additional Locations: CA-Concord
This position will be working from home and will require travel within the state of California

Accountable for audits and oversight of medical organizations and vendor relationships that perform Utilization Management (UM), Disease Management (DM), Case Management (CM) and Wellness on behalf of Aetna. Ensure timely review of audit documents by the appropriate committees.

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:
  • 3-5 years of quality management within clinical or managed care setting
  • Proficient use of Microsoft Office
  • Critical thinking skills and comfortable with working independently
  • Clinical licensure required (RN, LVN, LPN)
  • Must reside in California

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Ensuring Project Discipline

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 - TE Microsoft Excel

Nursing - Licensed Vocational Nurse/Licensed Professional Nurse (LVN/LPN), Nursing - Registered Nurse

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.

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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