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Quality Management Nurse Consultant

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
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Description:
This role is office based in Phoenix, AZ.

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

Fundamental Components:
-Reviews documentation and evaluates potential quality of care issues 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.
-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 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 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.

Background Experience:
-RN with current unrestricted state licensure required
-3+ years of clinical experience required
-Managed Care experience preferred
-Audit and precertification experience is preferred

Additional Job Information:
Typical office working environment with productivity and quality expectationsWork 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 environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Maximizing Work Practices, Leadership - Collaborating for Results

Desired Skills:
Service - Demonstrating Service Discipline, Service - Handling Service Challenges, Service - Improving Constituent-Focused Processes

Functional Skills:
Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Precertification, Medical Management - Medical Management - Clinical coverage and policies

Technology Experience:
Aetna Application - QNXT, Database - Intuit QuickBase, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Potential Telework Position:
Yes

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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