Aetna QM Nurse Consultant in Blue Bell, Pennsylvania

Req ID: 53384BR

POSITION SUMMARY

The QM Nurse Consultant is responsible for the quality oversight of the Territorial and Specialty Clinical Programs. The QM Nurse Consultant will review and evaluate clinical information and ensure documentation, integration points, and technology is utilized appropriately. The quality reviewer will review documentation and interpret data obtained from clinical records or systems to apply case management processes, appropriate clinical criteria and policies that are in line with regulatory and accreditation requirements for our members; requires an RN with an unrestricted active license with certification in CM preferred (CCM).

Fundamental Components:

Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations. 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. The QMNC 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 case management, clinical criteria, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information. Proactively 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. Demonstrates critical thinking. Engages in skilled, active, interpretation and evaluation of observations, communications, information, and argumentation. Gives due consideration to the evidence, context and relevant criteria surrounding the nature of a problem or question. Recognizes unstated assumptions and values, interprets data and evaluates arguments to make accurate judgments. Demonstrates intellectual humility, empathy, integrity, courage, and confidence to drive fair and purposeful judgment. Balances clinical and perceived quality with other outcome variables. Promotes cross-functional communication. Uses technology for audits, communication and reports.

BACKGROUND/EXPERIENCE desired:

  • Quality Review and Managed Care experience preferred

  • RN required

  • 3-5 years of clinical experience required

  • Certification in Case Management (CCM) is preferred.

  • Excellent verbal and written communication skills.

  • Strong data analysis and report preparation skills.

EDUCATION

The minimum 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 required

Nursing/Certified Case Manager (CCM) is desired

Nursing/Certified Professional in Healthcare Quality is desired

FUNCTIONAL EXPERIENCES

Functional - Nursing/Concurrent Review/discharge planning/1-3 Years

Functional - Nursing/Case Management/4-6 Years

Functional - Nursing/Medical-Surgical Care/1-3 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User

Technical - Desktop Tools/Microsoft Word/4-6 Years/End User

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

Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Benefits Management/Understanding Clinical Impacts/ADVANCED

Technology/Leveraging Technology/FOUNDATION

DESIRED SKILLS

Benefits Management/Maximizing Healthcare Quality/ADVANCED

General Business/Applying Reasoned Judgment/ADVANCED

Leadership/Collaborating for Results/ADVANCED

Telework Specifications:

Considered for any US location; training period in the office may be required.

ADDITIONAL JOB INFORMATION

This is an exciting time to join the quality team to support the Territorial and Specialty Clinical Programs. We are inspired to make a difference, and we are committed to integrity and clinical excellence. We strive to work together as a team to enhance the quality of services rendered by our staff.

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 Care