Quality Management Nurse ConsultantPrimary Location: Richmond, Virginia
Additional Locations: VA-Richmond Apply
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.
Standard business hours, no nights, no weekends or no holidays.
Fundamental Components but not limited to the following:
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.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
Typical office working environment with productivity and quality expectations
Managed Care experience preferred
3+ years of clinical experience required with quality emphasis is preferred
Experience with Medicaid or Medicare is preferred
Proficient with standard reporting and analysis
Strong writing skills
Knowledge of HEDIS NCQA and CAHPS is preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Healthcare Management/ is desired
An RN with unrestricted active license is preferred
An LPN at least is required
Functional - Quality Management/Quality Management/1-3 Years
Benefits Management/Interacting with Medical Professionals/ADVANCED
Leadership/Collaborating for Results/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
General Business/Turning Data into Information/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
ADDITIONAL JOB INFORMATION
A fast paced role that will ensure that we are an organization of Quality not with Quanity
The opportunity to work with a dedicated group of peers that focus on the member
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Aetna takes our candidates'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.
Jobs for you
Recently Viewed Jobs
You do not have any recently viewed jobs
Your Saved Jobs
You do not have any saved jobs
Sign up for Job Alerts
Join our Talent Community
At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.
Join Our Talent Community
Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.