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Quality Manager Nurse Consultant

Company: Aetna
Location: Harrisburg
Posted on: December 6, 2018

Job Description:

Req ID: 55770BR Telework Opportunity in Harrisburg, PA POSITION SUMMARY 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. Position will support a post pay process for clinical reviews. Fundamental Components: Evaluates documentation/information to determine compliance with clinical policy, regulatory, and accreditation guidelines Accurately applies review requirements to assure post pay reviews is reviewed based on clinical expertise for the issue Knowledge of contracts (provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of coding concepts and clinical information. Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines 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: Managed Care experience preferred 3-5 years of clinical experience required Technical/Database experience preferred as the role has analytical side around data EDUCATION The highest level of education preferred for candidates in this position is a Associate's degree or equivalent experience. LICENSES AND CERTIFICATIONS Nursing/Registered Nurse is required FUNCTIONAL EXPERIENCES Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years TECHNOLOGY EXPERIENCES Technical - Remote Access/WAH (Work at Home)/1-3 Years/End User Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User Technical - Desktop Tools/Microsoft Word/1-3 Years/End User REQUIRED SKILLS General Business/Applying Reasoned Judgment/ADVANCED Benefits Management/Interacting with Medical Professionals/ADVANCED ADDITIONAL JOB INFORMATION Post pay environment offering flexibility with multiple opportunities to learn editing/coding concepts and apply clinical knowledge to medical claim review. Role promotes independence, critical thinking, application of clinical judgment and decision making skills. 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. Job Function: Health CareAetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.

Keywords: Aetna, Harrisburg , Quality Manager Nurse Consultant, Healthcare , Harrisburg, Pennsylvania

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