Quality Management Nurse Consultant, HEDISPrimary Location: San Antonio, TX
Additional Locations: TX-San Antonio Apply
Partnering with providers to evaluate their current quality of care, identify gaps in care, and opportunities for improvement, and partner to bring forth initiatives and new processes that ultimately will result in our members receiving the prevention services and the treatment services that they need in order to realize their best health. Provides support for Healthcare Effectiveness Data and Information Set (HEDIS) quality initiatives and regulatory/contractual requirements including outreach to members who are noncompliant in the designated outreach services. Supports effective medical record capture for HEDIS medical record review and abstraction of supplemental data. 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.
64260Fundamental 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: 3+ years of clinical experience required
RN with current unrestricted state licensure required.
Managed Care experience preferred
HEDIS experience preferred
Additional Job Information:
Develop relationships with providers by evaluating their current quality of care, identify gaps in care, and opportunities for improvement, and partner to bring forth initiatives and new processes that ultimately will result in our members receiving the prevention services and the treatment services that they need in order to realize their best health. Provide support for Healthcare Effectiveness Data and Information Set (HEDIS) quality initiatives and regulatory/contractual requirements including outreach and provider office visits. Support effective medical record capture for HEDIS medical record review and abstraction of supplemental data.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.
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