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

Quality Management Nurse

Primary Location: Phoenix, Arizona
Additional Locations: AZ-Phoenix
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Description:

This is a telework role. Qualified applicants will reside in the state of Arizona.

Utilizes clinical skills to coordinate, document and communicate an investigation of quality of care concerns related to physical and/or behavioral health. Will participate in interdepartmental meetings related to quality along all lines of business.



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
Behavioral Health experience preferred



Additional Job Information:
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.
Ability to work in a fast-paced environment on a variety of clinical nursing cases involving both physical and behavioral health

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen, General Business - Maximizing Work Practices

Desired Skills:
General Business - Communicating for Impact, Leadership - Collaborating for Results

Functional Skills:
Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Disease management, Clinical / Medical - Quality management

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

Education:
Nursing - Registered Nurse (RN)

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. 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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