Aetna QM Nurse Consultant in Phoenix, Arizona
Req ID: 43760BR
Participate as a member of the Quality Management Department to improve integrated health care efforts among contracted providers. Responsible for conducting Quality of Care Concern investigations to ensure quality and compliance standards are met across the system.
Responsible for conducting Quality Of Care investigations to ensure delivery of service amongst contracted providers meets quality and compliance standards. Responsible for reviewing behavioral health and physical health records associated with identified member to assess quality of care. Responsible for navigating several data systems to collect pertinent data/information necessary for a thorough review. Responsible for formulating a comprehensive investigative summary response following records review. Will work in collaboration with the MMIC Medical Director to determine the result of presenting allegations and other potential allegations that might become evident during the investigation. Will also conduct on site investigations when necessary. Work in collaboration with the MMIC Medical Director to determine when a letter of concern, performance improvement plan, or corrective action plan is necessary to issue to an identified provider. Responsible for the written notification of any follow up action required of the identified provider. Responsible for the timely submission of Quality of Care Concerns to AHCCCS
Must hold active RN license in Arizona
Must have at least 2+ years experience performing RN duties
Experience performing quality reviews is preferred
Behavioral health experience is preferred
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
Functional - Nursing/Quality Management/1+ Years
Functional - Clinical / Medical/Quality management/1+ Years
Technical - Other//1+ Years/End User
Leadership/Fostering a Global Perspective/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
Leadership/Collaborating for Results/ADVANCED
General Business/Turning Data into Information/ADVANCED
ADDITIONAL JOB INFORMATION
After 6 month training period has completed, this position will transition to full time, work at home.
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.
Job Function: Health Care