Aetna Training & Qual Clinician in Pittsburgh, Pennsylvania
Req ID: 51661BR
Candidates must reside in PA or FL - work at home opportunity
POSITION SUMMARYResponsible for conducting audits of current processes, reports, and procedures to identify process improvements and issue resolutions. Develops and conducts medical management staff training based on outcomes of clinical audits.
Fundamental Components:Provides ongoing and random qualitative and quantitative analysis of the business process, clinical systems, tools, and staff competencies using organizational performance measurements to ensure compliance with government regulations and corporate policy. Reviews and evaluates internal controls are in place to ensure ongoing compliance. Identifies, documents, and reports any transaction errors in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Recommends corrective action and facilitates the implementation of remedial and process improvement plans. Develops and conducts medical management staff training based on outcomes of clinical audits. Implements training programs to increase role specific consistencies and efficiencies related to process work flows. Measures outcomes of clinical staff training and identifies key findings to ensure effective alignment of training content and method of delivery with business objectives and staff performance requirements. Promotes continuing compliance with accreditation and/or applicable regulatory body requirements including but not limited to: company's ethical, fraud, abuse, and compliance policies and expectations, utilization management policies, procedures and workflows, key accreditation standards, and HIPAA regulatory standards related to use of PHI. Facilitates communication of relevant findings to corporate Compliance Department and/or Corporate Privacy/ Security Officer. Performs other duties as required.
BACKGROUND/EXPERIENCE:Previous (3-5 years) experience in a managed care clinical operations environment (utilization management, case management, and/or behavioral health case management) required.Experience in designing, developing, and instructing training programs.Excellent verbal and written communication skills.Strong data analysis and report preparation skills.Ability to use standard corporate software packages and corporate applications.
EDUCATIONThe highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONSNursing/Registered Nurse is requiredNursing/Licensed Social Worker (LCSW) is preferred
FUNCTIONAL EXPERIENCESFunctional - Nursing/Case Management/4-6 YearsFunctional - Nursing/Concurrent Review/discharge planning/4-6 YearsFunctional - Nursing/Quality Management/4-6 Years
TECHNOLOGY EXPERIENCESTechnical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
ADDITIONAL JOB INFORMATIONAetna 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: Health Care