This is an in office position in Aetna's Linthicum, MD office. Occasional telework can be considered after a period of orientation and demonstrated performance.
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. Requires an RN with unrestricted active license.
Duties include processing of quality referrals, leading HEDIS related quality improvement teams, collection and analysis of data, clinical review of credentialing files as needed and support for HEDIS medical record review as needed. Applicant should be able to function independently and meet strict processing deadlines. Good written and oral communication skills required. This position involves coordination and prioritization of multiple tasks concurrently.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Healthcare Management/Certified Professional in HealthCare Quality (CPHQ) is desired
Healthcare Management/Certified Utilization Review (CPUR) is desired
Nurses/Registered Nurse (RN) is required
Nursing/Quality Management/1-3 Years
Quality Management/Credentialing/1-3 Years
Medical Management/Clinical coverage and policies/1-3 Years
Quality Management/HEDIS experience/1-3 Years
Desktop Tools/Microsoft Excel/4-6 Years
Desktop Tools/Microsoft PowerPoint/4-6 Years
Desktop Tools/Microsoft Word/4-6 Years
Desktop Tools/Microsoft Visio/4-6 Years
Benefits Management/Interacting with Medical Professionals
Benefits Management/Maximizing Healthcare Quality
General Business/Applying Reasoned Judgment
General Business/Turning Data into Information
Leadership/Collaborating for Results
Leadership/Driving a Culture of Compliance