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Registered Nurse (RN) - Quality Management Nurse Consultant
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Atlanta, Georgia |
About this job
Candidates must have at least 1 year of clinical nursing experience. Coding experience is strongly preferred.
This is a work at home position.
POSITION SUMMARY
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.
Fundamental Components:
Reviews documentation and evaluates potential correct coding issues based on multiple clinical policies. 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 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 desired:
Managed Care experience preferred
1-3 years of clinical experience required
Coding experience preferred
EDUCATION
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 (RN) is required
FUNCTIONAL EXPERIENCES
Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years
TECHNOLOGY EXPERIENCES
Technical - Remote Access/WAH (Work at Home)/
Technical - Computer Operations/System and Console Operations/
REQUIRED SKILLS
Benefits Management/Interacting with Medical Professionals/
General Business/Applying Reasoned Judgment/
Benefits Management/Understanding Clinical Impacts/
DESIRED SKILLS
Technology/Leveraging Technology/
Telework Specifications:
Full-Time Telework (WAH)
Considered for any US location; training period in the office may be required
ADDITIONAL JOB INFORMATION
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 hear
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.
We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Employment Type Regular Career Band Description Professional
This is a work at home position.
POSITION SUMMARY
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.
Fundamental Components:
Reviews documentation and evaluates potential correct coding issues based on multiple clinical policies. 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 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 desired:
Managed Care experience preferred
1-3 years of clinical experience required
Coding experience preferred
EDUCATION
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 (RN) is required
FUNCTIONAL EXPERIENCES
Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years
TECHNOLOGY EXPERIENCES
Technical - Remote Access/WAH (Work at Home)/
Technical - Computer Operations/System and Console Operations/
REQUIRED SKILLS
Benefits Management/Interacting with Medical Professionals/
General Business/Applying Reasoned Judgment/
Benefits Management/Understanding Clinical Impacts/
DESIRED SKILLS
Technology/Leveraging Technology/
Telework Specifications:
Full-Time Telework (WAH)
Considered for any US location; training period in the office may be required
ADDITIONAL JOB INFORMATION
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 hear
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.
We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Employment Type Regular Career Band Description Professional
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