Aetna Health Care QM Project Manager in Baton Rouge, Louisiana

Req ID: 49638BR


CPC (Certified Professional Coder) certification or CRC (Certified Risk Adjustment Coder) certification required.

Some travel is required.

This position is crucial to clinical quality (Medicare Stars) and provider coding activities. As an educator, consultant and program leader, this role will be instrumental in cultivating partnerships with internal stakeholders and external provider groups in driving improvements to Stars and revenue outcomes that are critical to the sustainability and growth of Aetna's Deep South markets.

Fundamental Components:

Development, implements and leads homegrown programs that are integral to Stars and revenue improvements.

Establishes and leverages relationships with internal Aetna departments and external physician groups to help drive success.

Uses clinical skills to assess, plan, monitor, and evaluate healthcare services in the provider office setting.

Responsible for educating providers on how to properly document medical services and interventions received during

face to face member encounters, including proper coding and claim submission for services rendered.

Reviews performance scorecards with physician partners, troubleshoots data issues and initiates action plans to facilitate improvements.

Serves as a liaison to peers in sharing best practices, identifying and recommending opportunities for process improvements to improve overall coding accuracy and gap closure; provides in-depth clinical knowledge and expertise to support the education of providers.

Performs audits of medical records to ensure coding is accurate and supported by written clinical documentation.

Identifies barriers utilizing critical thinking skills to identify improvement opportunities, communicate them to the national team, and help facilitate gains in efficiency and appropriate risk score capture.

Serves as the training resource and subject matter expert to regionally aligned network practices.

Identifies opportunities to promote quality.

Shares best practices in risk adjustment across all sites/regions.

Simultaneously manages multiple, complex projects


CPC (Certified Professional Coder) certification or CRC (Certified Risk Adjustment Coder) certification required.

Strong knowledge of clinical quality and Medicare 5 stars experience is required

Experience in Medicare risk adjustment, including a minimum of 3+ years recent and related experience in medical record documentation review, diagnosis coding, and/or coding education is required

Excellent Excel and data/analytics skills are required


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


Functional - Project Management/Project Leader/1+ Years

Functional - Communications/Provider communications/3+ Years


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

Technical - Desktop Tools/


Leadership/Anticipating and Innovating/ADVANCED

Leadership/Creating Accountability/ADVANCED


Service/Working Across Boundaries/MASTERY


This position is part of a high performing team that fosters innovation of ideas, empowerment and creativity. Great opportunities for upward mobility and leadership path within Aetna.

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 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.

Job Function: Quality Management