TX STAR+PLUS QM Nurse ConsultantPrimary Location: Dallas, TX
Additional Locations: TX-Dallas Apply
- Performs HEDIS and other quality metric related reviews of documentation and evaluates quality implications based on clinical policies and benefit determinations.
- Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
- Works with HEDIS medical record reviewers to assess accuracy of HEDIS determinations.
- Data gathering requires navigation through multiple system applications.
- Staff may be required to contact the providers of record, vendors, 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.
- Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the 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.
- 3+ years of clinical experience required
- Managed Care experience preferred
- RN with current unrestricted state licensure required.
- Typical office working environment with productivity and quality expectations.
- Work requires the ability to perform close inspection of hand written 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.
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