Aetna QM Nurse Consultant (RN) - KS MCD - 51954BR in Overland Park, Kansas

Req ID: 51954BR

Position Summary:

The Quality Management (QM) Nurse Consultant facilitates the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. The QM Nurse Consultant develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

The QM Nurse Consultant is also responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets 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 unrestricted active Registered Nurse Licensure.

Additional Responsibilities of the Quality Management Nurse Consultant:

  • 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. Staff may be required to contact the providers of record, vendors, or 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 complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.

  • Pro-actively 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.

    Required Skills for the Quality Management Nurse Consultant:

  • 3-5 years of clinical experience.

  • Managed Care OR Clinical Quality (Healthcare Effectiveness Data and Information Set or HEDIS/Chart Review) experience.

  • Proficiency with MS Office Suite, navigating multiple systems and keyboarding.

  • Exceptional verbal, written and presentation communication skills.

  • Ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

  • Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

  • Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.

  • Typical office working environment with productivity and quality expectations.

    Preferred Skills for the Quality Management Nurse Consultant:

  • Bachelor of Science in Nursing

    EDUCATION

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

    (BSN preferred)

    LICENSES AND CERTIFICATIONS

    Nursing/Registered Nurse with current unrestricted KS state licensure (RN) is Required

    FUNCTIONAL EXPERIENCES

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

    TECHNOLOGY EXPERIENCES

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

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

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

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

    REQUIRED SKILLS

    Benefits Management/Maximizing Healthcare Quality/ADVANCED

    Benefits Management/Understanding Clinical Impacts/ADVANCED

    General Business/Applying Reasoned Judgment/ADVANCED

    DESIRED SKILLS

    Benefits Management/Interacting with Medical Professionals/ADVANCED

    Finance/Managing Aetnas Risk/ADVANCED

    Leadership/Collaborating for Results/ADVANCED

    ADDITIONAL JOB INFORMATION

    Are you ready to join a company that is changing the face of health care across thenation? Aetna Better Health of Kansas is looking for people like you who valueexcellence, integrity, caring and innovation. As an employee, you’ll join ateam dedicated to improving the lives of KanCare members. Our visionincorporates community-based health care that works. We value diversity. Alignyour career goals with Aetna Better Health of Kansas, and we will support youall the way.

    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.

    #LI-KK1

Job Function: Health Care

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.