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TX STAR+PLUS Disease Management QM Nurse

Primary Location: Dallas, TX
Additional Locations: TX-Dallas
This position is responsible for operationalizing the health plan Disease Management/Population Health (DM/PH) strategic plan. Critical tasks include actions to monitor disease management program offerings that use advanced analytics technology to identify and intervene with moderate risk populations to improve care and reduce emergency room use. These program offerings are managed by vendors and internal Aetna health care improvement teams but need monitoring actions to ensure the plan goals and objective are met Use NCQA population health standards and guidance for planning new initiatives to meet the DM/PH needs of members with more complex clinical profiles. Development and execution of DM/PH strategies to improve HEDIS rates. Responsible for the review and evaluation of clinical information and documentation. Requires an RN license with unrestricted active license. This position is office based; eligible for part time telework consideration after 90 days and demonstrated performance.

Fundamental Components:
• Coordinating DM/PH related care and services between the health plan care management and quality teams and our provider community
• Monitoring analytics and utilization trends including high-risk and emerging-risk member identification and early identification of care intervention opportunities
• Work across the provider and local care and service community to drive relationships and partnerships and care coordination opportunities to ensure the full continuum of care is available to our members including building relationships with LTSS, behavioral health, pharmacy, home and community- based providers, patient-centered medical homes, health homes, community mental health centers
• Champion the execution of DM/PH care strategies
• Work with our provider partners, QM, CM other stakeholders and national shared services team to enhance, establish or refine provider workflows to create common procedures and protocols to best meet our members’ needs which include but are not limited to readmission programs, transitions of care, quality gaps in care and of alignment with the health plan integrated care management team
• Participate in regular meetings with provider and vendor clinical care teams to promote optimal care coordination, program innovation, and clinical decision making.,
• Other population health related activities as those activities are defined during the development of segment disease management/population health strategies
• 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.
  • 3+ years of clinical experience required.
  • Managed Care experience preferred.
  • Experience within a health plan, an accountable care organization and/or population health management unit or patient-centered medical home function within a provider organization, is preferred.
  • Excellent written, verbal and presentation skills, equally comfortable presenting to the providers’ senior leadership, the clinical teams or meeting directly with members in a care setting.
  • Care management experience with either a provider or health plan
  • Demonstrated analytical and critical thinking skills – ability to use analytics and data trends to drive care management, risk stratification and predictive modeling
  • Project management skills- ability to manage many relationships simultaneously and simultaneously lead several initiatives - able to hit targets, deadlines and proactively establish day-to-day priorities
  • Strong collaboration and team-building skills – ability to maintain and grow high performing relationships and programs
  • 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.
  • Ability to use analytics and population health management tools to drive clinical decision making and point-of-care service delivery

Additional Job Information:
  • Experience with Medicaid, duals or special needs populations is a plus
  • Understanding of integrated care management- the biopsychosocial model, public health, care transitions, population health management strategies, community-based care coordination models and clinical-decision-making tools is a plus
  • Participation with healthcare delivery transformation or re-design projects (e.g. community-mental health centers, patient-centered medical homes) is a plus
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 - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality

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

Functional Skills:
Clinical / Medical - Disease management, Clinical / Medical - Quality management, Medical Management - Medical Management - Disease management, Nursing - Disease management

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

Nursing - Registered Nurse (RN)

Potential Telework Position:

Percent of Travel Required:
0 - 10%

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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