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Position Summary

This is a full-time remote Quality Management Nurse Consultant opportunity. Working schedule is Monday-Friday, 8am-5pm in time zone of residence with flexibility to work outside of business hours, as needed.

• Works Potential Quality of Care cases (Medical), along with Patient Safety Events across all lines of business (Commercial, Medicare, and Medicaid). 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.
• 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 critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• This position 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 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.
• The incumbent must demonstrate strong clinical judgement as well as knowledge of internal systems.

• Current unrestricted compact RN license
• 3+ years of clinical experience
• 2+ years of acute care experience e.g., hospital setting or ambulatory care including critical care, ICU, ER, Med/Surg, OR
• 2+ years' experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)

• Willing and able to obtain additional state licenses upon hire (Paid for by the company)
• Experience working Grievance cases
• Appeals experience
• Case Management or Utilization Management experience
• Managed care experience
• Medicaid experience
• Systems experience: ATV, ASD, GPS, MedCompass, QNXT, Dynamo, HRP, MedHok
• Critical thinking skills
• Previous experience working in a remote/virtual environment

• Minimum of Associates or Diploma in Nursing required
• BSN degree preferred