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Aetna Quality Management Nurse Consultant (HEDIS) - 56570BR in San Antonio, Texas

Req ID: 56570BR

Job Description

This is an office based position in the San Antonio, TX office. Previous HEDIS experience is strongly preferred.

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 accred

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Fundamental Components included but are not limited to:

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.

Qualifications Requirements and Preferences:

3+ years of clinical experience required

RN with current unrestricted state licensure required.

HEDIS experience strongly preferred

Managed Care experience preferred

Additional Job Information:

Typical office working environment with productivity and quality expectations

Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

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

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

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Effective communication skills, both verbal and written.

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

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.

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