Aetna RN- Site Review- Nurse Consultant- Registered Nurse in W. Sacramento, California
Req ID: 43282BR
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.
The Site Review Nurse Consultant position is responsible for the review and evaluation of clinical information and documentation and QM FSR(Facility Site Reviews). In this role you will review documentation and interpret 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. This role independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.
This is an exciting opportunity to become part of a brand new plan and become certified in site review if you are not already! This role will be 75% local travel to sites and then 2 days in the office depending on schedules of site visits.
-Conducts audits on network offices-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.
Managed Care experience is preferred. 3-5 years of clinical experience required. RN with current unrestricted state licensure required. Certified Site Reviewer would be a huge plus! HEDIS experience is a plus! Position requires proficiency with MS Office Suite and navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN)
Functional - Clinical / Medical/Quality management/4-6 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years
Functional - Medical Management/Medical Management - Clinical coverage and policies/4-6 Years
Technical - Desktop Tools/Microsoft Word/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
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Benefits Management/Understanding Clinical Impacts/ADVANCED
Benefits Management/Maximizing Healthcare Quality/ADVANCED
General Business/Demonstrating Business and Industry Acumen/ADVANCED
Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Turning Data into Information/ADVANCED
ADDITIONAL JOB INFORMATION
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