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

Clinical Health Care QM Manager

Primary Location: Phoenix, Arizona
Additional Locations: AZ-Phoenix, CO-Denver, CT-Hartford, MO-Kansas City, NV-Reno, OH-New Albany, PA-Blue Bell, TX-Dallas, TX-Houston
The ideal candidate will perform clinical and coding reviews of complex claim billing scenarios and associated electronic
medical records (EMRs) for Medical Policy & Program Solutions. Candidate will identify potential claim editing and clinical program enhancements based on reviews.

Fundamental Components:

Perform clinical and coding reviews and conduct root cause analysis to validate any issues with Medical Policy claim
edits and clinical programs.

Validate claim data for accuracy and confirm the billed coding matches the patient’s medical history. This includes research of medical coding standards across the industry and code sources.

Identify potential waste and abuse by performing audits of electronic medical and/or hospital records to validate
proper coding guidelines were followed on the billed claims.

Partner with Medical Economics, Special Investigations Unit, and clinical leadership to develop medical cost containment solutions to manage waste and abuse via new and/or enhanced claim edits or other clinical review programs.

Background Experience:

Registered, RN OR LPN nurse
Current medical coding certification from recognized national organizations

1-3 years of clinical coding of electronic medical record experience in the health care industry
Experience in performing EMR reviews to confirm that industry coding standards were followed

Must be familiar with claim editing software to propose system changes
Must be familiar with medial classification and categorization recommendations, such as those used in EMR software

Proven track record in meeting project milestones and negotiating for resources
Excellent verbal and written communication skills

Additional Job Information:
Understanding of trends and constituency expectations.

Required Skills:
General Business - Communicating for Impact, General Business - Consulting for Solutions, Service - Working Across Boundaries

Desired Skills:
General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen, General Business - Ensuring Project Discipline

Functional Skills:
Claim - Claim processing - Medical or Hospital - ACAS, Claim - Policies & procedures, Clinical / Medical - Clinical claim review & coding

Technology Experience:
Operating System - Windows

Medical Management - AMA Certificate - Procedural Coding and Reporting, Medical Management - Certified Coding Specialist, Medical Management - Certified Coding Specialist-Physicians (CCS-P)

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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