Aetna Training & Quality Clinician in Detroit, Michigan
Req ID: 62784BR
Responsible 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 included but are not limited to:
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.
Qualifications Requirements and Preferences:
Excellent verbal and written communication skills; Required
Experience in designing, developing, and instructing training programs; Preferred
Ability to use standard corporate software packages and corporate applications; Required
3+ years of experience in a managed care clinical operations environment (utilization management, case management, and/or behavioral health case management) Required
Strong data analysis and report preparation skills; Required
Current clinical license in the state where job duties are performed is Required based on the clinical sector supported and may include any of the following: RN or LMSW
Mental Health - Licensed Master Social Worker (LMSW), Nursing - Registered Nurse, Nursing - Registered Nurse (RN)
General Business - Communicating for Impact, Leadership - Collaborating for Results, Service - Working Across Boundaries
General Business - Maximizing Work Practices, Leadership - Anticipating and Innovating, Leadership - Driving a Culture of Compliance
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Healthcare
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.