QM Nurse Consultant (RN) - KS MCD - 51954BR
Overland Park, KS
Facilitates the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.
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.
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.
3-5 years of clinical experience; Required
Managed Care OR Clinical Quality (HEDIS / Chart Review) experience; Required
Proficiency with MS Office Suite, navigating multiple systems and keyboarding; Required
Exceptional verbal, written and presentation communication skills; Required
Ability to perform close inspection of hand written and computer generated documents as well as a PC monitor; Required
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment; Required
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
Typical office working environment with productivity and quality expectations
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse with current unrestricted KS state licensure (RN) is Required
Functional - Quality Management/Quality Management/4-6 Years
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User
Benefits Management/Maximizing Healthcare Quality/ADVANCED
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
Benefits Management/Interacting with Medical Professionals/ADVANCED
Finance/Managing Aetnas Risk/ADVANCED
Leadership/Collaborating for Results/ADVANCED
ADDITIONAL JOB INFORMATION
Areyou ready to join a company that is changing the face of health care across thenation? Aetna Better Health of Kansas is looking for people like you who valueexcellence, integrity, caring and innovation. As an employee, you’ll join ateam dedicated to improving the lives of KanCare members. Our visionincorporates community-based health care that works. We value diversity. Alignyour career goals with Aetna Better Health of Kansas, and we will support youall the way.
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.
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.