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Id61lj5y6533s44cr9r

Quality Management Nurse

Aetna Phoenix Full-Time
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This role requires onsite training in Downer's Grove, IL. After successful training and proven performance position will become telework.

25-50% of local travel is required


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 accred

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: 
3+ years of clinical experience required
Managed Care experience preferred
RN with current unrestricted state licensure required.

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.


Potential Telework Position: 
No

Percent of Travel Required: 
25 - 50%

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.

Recommended skills

Navigation
Communication
Computer Literacy
Accreditation
Typing
Documentation
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