TX STAR+PLUS Delegation Oversight Nurse ConsultantPrimary Location: Dallas, TX
Additional Locations: TX-Dallas Apply
- 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
- 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.
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