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A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Health Care QM Manager

Primary Location: Hartford, CT
Additional Locations: CT-Hartford
We are building an exciting new clinical and member experience program at Aetna. Aetna Community Care is a member centric, team-delivered, community based care management model that joins members where they are. The Quality Review Nurse (QRN) is responsible for the review and audit of clinical records to promote and support care management quality and best practice under the guidance of the Director, Health Care Quality Management. The QRN works to assure program efficacy, accreditation and compliance, fostering a collaborative culture of continuous quality improvement to optimize member and associate experience, and to support clinical and business outcomes.

Fundamental Components:
Conducts documentation and phone call reviews for member facing clinical staff to assure adherence to policy and procedures, regulatory compliance and promote best practice standards • Collaborates with quality team to develop and test pertinent audit tools designed to meet targeted review objectives and inter-rater reliability • Supports the work of clinical supervisor associate reviews including field, in-home assessment reviews and ride-alongs • Builds relationships and establishes credibility as an expert clinical quality resource • Prepares, analyzes and applies pertinent audit data, metrics and reports to monitor, trend and track associate and team performance, member and program outcomes • Provides objective constructive feedback to address audit deficits and trends; providing recommendations for corrective action and improvement • Develops methods for an ongoing feedback loop with all identified stakeholders, e.g. clinical leaders, clinical associates, clinical teams • Creates a trusting, collaborative culture and processes for continuous quality improvement • Liaison with clinical leadership, Learning & Performance, providing input for process improvement and new or refresher trainings • Participates with the leadership team and actively contributes to program best practice standards and strategies • Adheres to protocols and processes in compliance with regulatory guidelines and company policies and procedures • Responsible for completing all mandatory and program specific trainings and other responsibilities as required.

Background Experience:
The minimum level of education required for candidates in this position is a Bachelor’s degree in Nursing (BSN) • Bachelor's degree, Nursing degree, or other comparable healthcare experience. Minimum of 3 years’ case management experience required • 5 years’ clinical practice experience required • Clinical quality review/audit experience required; e.g. Audit tool development • Community, public health, home health, outpatient experience preferred • Working knowledge of care management, NCQA, best practice e.g. care plans/SMART goals • The ability to express oneself clearly both verbally and in writing; motivational interviewing or related skills desired • Experience in healthcare, managed care, insurance industry preferred • Certified Managed Care Nurse (CMCN), Certified Case Manager (CCM) or Quality certification preferred • The ability to work in a dynamic environment and balance priorities.

Nursing - Certified Case Manager (CCM), Nursing - Registered Nurse

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. Click here to review the benefits associated with this 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.

Click To Review Our Benefits (PDF)


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