Aetna Quality Review Nurse in Harrisburg, Pennsylvania

Req ID: 55892BR

Position Summary:

We are building an exciting new clinical and member experience program at Aetna. Aetna Community Care is a member centric, team-delivered, community-based care management model that joins members where they are.

The Quality Review Nurse (QRN) is responsible for the review and audit of clinical records to promote and support care management quality and best practice for Aetna Community Care, a new community-based care management program in New Jersey. The QRN reports to the works to assure program efficacy, accreditation and compliance, fostering a collaborative culture of continuous quality improvement to optimize member and associate experience, and to support clinical and business outcomes.

Job Responsibilities:

  • Designs and conducts clinical documentation and phone call reviews for member facing clinical staff to assure adherence to policy and procedures, regulatory compliance and promote best practice standards

  • Develops and tests pertinent audit tools designed to meet targeted review objectives and inter-rater reliability

  • Supports the work of clinical supervisor associate reviews including field, in-home assessment reviews and ride-along shadowing

  • Builds relationships and establishes credibility as an expert clinical quality resource

  • Prepares, analyzes and applies pertinent audit data, metrics and reports to monitor, trend, and track associate and team performance, member and program outcomes

  • Provides objective constructive feedback to address audit deficits and trends; providing recommendations for corrective action and improvement

  • Develops methods for an ongoing feedback loop with all identified stakeholders, e.g. clinical leaders, clinical associates, clinical teams

  • Creates a trusting, collaborative culture and processes for continuous quality improvement

  • Liaison with clinical leadership, Learning & Performance, providing input for process improvement and new or refresher trainings

  • Participates with the leadership team and actively contributes to program best practice standards and strategies

  • Adheres to protocols and processes in compliance with regulatory guidelines and company policies and procedures

  • Responsible for completing all mandatory and program specific trainings and other responsibilities as required

  • Other responsibilities as required

    Background/ Experience Desired:

  • Minimum of 3 years case management experience required

  • 5 years clinical practice experience required

  • Clinical quality review/audit experience required; e.g. Audit tool development

  • Community, public health, home health, outpatient experience preferred

  • Working knowledge of care management, NCQA, best practice e.g. care plans/SMART goals

  • Effective communicator; motivational interviewing or related skills desired

  • Experience in healthcare, managed care, insurance industry preferred

  • Certified Managed Care Nurse (CMCN), Certified Case Manager (CCM) or Quality certification preferred

  • The ability to work in a dynamic environment and balance priorities

  • Bilingual (Spanish) preferred


  • The minimum level of education required for candidates in this position is a Bachelors degree in Nursing (BSN)

  • Masters Degree preferred (Nursing or other related discipline)

    Licensures/ Certifications:

  • Registered Nurse (RN); active state license in good standing required.

  • Nursing/ Certified Case Manager (CCM) is desired.

  • Nursing/ Academy of Certified Case Managers is desired.

    Telework Specifications:

  • Position to be located in the Harrisburg, PA office or work at home in New Jersey preferred. Can be located anywhere in U.S.

    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. 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.

    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.

    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: Quality Management

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.