Aetna Quality Management Nurse Consultant (HEDIS) in San Antonio, Texas
Req ID: 56570BR
This is an office based position in San Antonio, TX
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 accreditation requirements for member and/or provider issues. Independently coordinates the clinical
resolution with internal/external clinician support as required.
Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
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 information; condenses complex information into a clear and precise clinical picture while working independently.
Staff will be required to discuss with members and providers gaps in care related to wellness and preventive care services.
Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes that are required to support the review of the clinical documentation/information.
Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.
Participates in meetings and committees with internal and external participants including clients, vendors and accreditation personnel.
Works closely with other members of the department on various quality projects including medical record collection and review, provider and member outreach, data entry in multiple systems and other activities based on business need.
3+ years of clinical experience required
HEDIS background experience strongly preferred
Managed Care experience preferred
Quality Management Experience 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
Managed Care/Managed Healthcare Professional is preferred
Functional - Nursing/Quality Management/4+ Years
Technical - Desktop Tools/Microsoft Outlook/1+ years
Technical - Desktop Tools/Microsoft SharePoint/1+ years
Technical - Desktop Tools/Microsoft PowerPoint/1+ years
Benefits Management/Interacting with Medical Professionals/ADVANCED
Benefits Management/Maximizing Healthcare Quality/ADVANCED
Benefits Management/Understanding Clinical Impacts/ADVANCED
In office position only.
ADDITIONAL JOB INFORMATION
The opportunity to work with an amazing team, while independently managing and prioritizing various tasks. If you are looking for a position where you can have a positive impact on members health and wellness, as well as work collaboratively with providers to close gaps in care.
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.