Skip to main content

Quality Management Nurse Consultant

Primary Location: Richmond, VA
Additional Locations: VA-Richmond
Apply
Description:
Quality Management Nurse Consultant
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 interpretation according to HEDIS technical specifications. Independently coordinates with internal departments as well as external providers to improve documentation and coding according to NCQA and HEDIS requirements. Requires an RN with unrestricted active license.

Fundamental Components:
Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. Accurately applies review requirements to assure all audit requirements are met. 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:
Responsibilities will include HEDIS, credentialing and site audits as necessary.

3 years of clinical experience required
HEDIS experience required
Quality experience required
Managed Care experience preferred

RN with current unrestricted state licensure required.


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.

Functional Skills:
Quality Management - Quality Management

Education:
Nursing - Registered Nurse

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.

Apply

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.