Health Care QM Consultant (Work at Home)

POSITION SUMMARY

Accountable for audits and oversight of medical organizations and vendor relationships that perform Utilization Management (UM), Disease Management (DM), Case Management (CM) and Wellness on behalf of Aetna. Ensure timely review of audit documents by the appropriate committees.

Fundamental Components:

Organize and maintain all documents related to the oversight process. Track customer compliance with timely submission of oversight documents as related to regulatory requirements and policies as well as monitor/track compliance with requirements. This position supports NCQA, CMS, and other regulatory compliance initiatives through compliance oversight. Serves as a resource and subject matter expert on aspects of quality programs and accreditation standards while building a strong collaborative relationship with IPAs and Medical Groups. Support internal constituents and business partners through sharing of QM activities. Support achievement of NCQA Accreditation. Communicate to delegated entities about industry standards, Aetna policies, and best practices to improve overall quality program. Identify and communicate trends. Report results and make recommendations. Support external constituents and industry collaboratives.

BACKGROUND/EXPERIENCE desired:

3+ years work related experience in the healthcare industry.

5 to 7 years clinical and/or managed care experience in the healthcare industry and quality management.

Proficient use of Microsoft office suite.

Highly skilled computer literacy, critical thinking skills

RN, LPN, or LCSW required

Able to influence without direct authority

EDUCATION

The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

LICENSES AND CERTIFICATIONS

One of the following licenses is required:

Nursing/Licensed Practical Nurse (LPN) is required

Nursing/Licensed Social Worker (LCSW) is required

Nursing/Registered Nurse (RN) is required

FUNCTIONAL EXPERIENCES

Functional - Quality Management/Quality Management/4-6 Years

Functional - Quality Management/FE NCQA accreditation/4-6 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Adobe Acrobat Suite v5/1-3 Years/End User

Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User

Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User

REQUIRED SKILLS

Leadership/Collaborating for Results/ADVANCED

Leadership/Creating Accountability/ADVANCED

Leadership/Driving a Culture of Compliance/ADVANCED

DESIRED SKILLS

Service/Improving constituent-focused Processes/ADVANCED

General Business/Turning Data into Information/ADVANCED

Telework Specifications:

Full-Time Telework (WAH)

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 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