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TX STAR+PLUS Delegation Oversight Nurse Consultant

Primary Location: Dallas, TX
Additional Locations: TX-Dallas
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Description:
Responsible for the review and evaluation of clinical, delegate and vendor information and documentation to establish that delegates and vendors meet contract requirements. Reviews documentation and interprets data obtained from clinical records, reports or systems to apply appropriate clinicalcriteria 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. This position may be required to make occasional site visits to vendor offices.Travel will be 15% of the time, with personal vehicle. Must have active and valid TX driver's license, reliable transportation and vehicle insurance.This position is office based; eligible for part time telework consideration after 90 days and demonstrated performance.

Fundamental Components:
  • Reviews documentation and evaluates potential quality of care issues and other issues based on vendor and state reports.
  • 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 delegate or vendor, providers of record, 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 and service criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the decisions regarding delegate and vendor performance and 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 with current unrestricted state licensure required.
  • 2+ years of experience working with healthcare vendors required.
  • 3+ years of clinical experience required.
  • Managed Care experience is preferred.
  • Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
  • Typical office working environment with productivity and quality expectations.
  • Work requires the ability to perform close inspection of handwritten 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.


Additional Job Information:
At Aetna Better Health of Texas, we are committed to helping people on their path to better health. By taking a total and connected approach to health, we guide and support our members so they can get more out of life, every day. We are 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 Texas STAR+PLUS, STAR/CHIP, and STAR Kids members. We value diversity and are dedicated to helping you achieve your career goals.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, General Business - Maximizing Work Practices

Desired Skills:
Benefits Management - Supporting Medical Practice, General Business - Communicating for Impact, Leadership - Collaborating for Results

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

Education:
Nursing - Registered Nurse (RN)

Potential Telework Position:
No

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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