Aetna QM Nurse Consultant in Sunrise, Florida
Req ID: 43670BR
Candidate must work out of ANY Aetna USA office that is in commutable distance with the exception of PA offices.
The Quality Management Nurse Consultant is responsible for reviewing documentation and interpreting 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.
Fundamental Components included but not limited to:
Responsible for reviewing documentation and interpreting 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 Oral Surgery requests. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.
-At least 1-2 years ofexperience assisting with Oral Surgery procedures is required
-Experience reviewing Insurance plans and benefits is preferred
-Requires an RN with unrestricted activelicense
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS:
Nursing/Registered Nurse (RN) is desired
Functional - Nursing/Clinical coverage and policies/1-3 Years
Functional - Nursing/Clinical claim review and coding/1-3 Years
Functional - Clinical / Medical/Precertification/1-3 Years
Technical - Aetna Applications/Aetna Total clinical View/1-3 Years/End User
Technical - Aetna Applications/Active Health Interface/1-3 Years/End User
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
Benefits Management/Interacting with Medical Professionals/ADVANCED
Telework considered only for unique circumstances.
ADDITIONAL JOB INFORMATION:
We are looking for a nurse with Oral Surgery background to perform reviews for Oral Maxillofacial Surgical procedures.
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.
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Job Function: Health Care