Aetna Quality Manager Nurse Consultant in Harrisburg, Pennsylvania
Req ID: 55770BR
Telework Opportunity in Harrisburg, PA
Reviews documentation and interprets 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. Position will support a post pay process for clinical reviews.
Evaluates documentation/information to determine compliance with clinical policy, regulatory, and accreditation guidelines
Accurately applies review requirements to assure post pay reviews is reviewed based on clinical expertise for the issue
Knowledge of contracts (provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of coding concepts and clinical information.
Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines
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 preferred
3-5 years of clinical experience required
Technical/Database experience preferred as the role has analytical side around data
The highest level of education preferred for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is required
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years
Technical - Remote Access/WAH (Work at Home)/1-3 Years/End User
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
General Business/Applying Reasoned Judgment/ADVANCED
Benefits Management/Interacting with Medical Professionals/ADVANCED
ADDITIONAL JOB INFORMATION
Post pay environment offering flexibility with multiple opportunities to learn editing/coding concepts and apply clinical knowledge to medical claim review. Role promotes independence, critical thinking, application of clinical judgment and decision making skills.
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 candidates'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
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.