Direct Employer
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. 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 review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. 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 the 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
Direct Employer
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 review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.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 the 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.
Direct Employer
This position is accountable for health care quality projects and initiatives through direction setting and leadership. Assimilates information to proactively develop quality activities aligned with company strategies and values. Links the quality management activities to business goals. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on aspects of the quality program to develop and influence business strategies.#LI-TS1For the Kentucky SKY program, this position also includes, but not limited to, functions such as: Quality of care monitoring, HEDIS measure reporting, education and monitoring, risk score and persistency data, Trauma informed care training and education, Adverse Childhood Event training and education, HEERO (Helping Each other/Everyone Reach Out) education and training, and quality strategy for medically complex population.)Fundamental ComponentsMakes business decisions based on the results of research and data analysis.Has responsibility for decision making regarding the design, development, and implementation strategy of quality improvement projects, and initiatives.May manage a QM functional department including development and oversight of performance metrics and application of HR policies and procedures.Forms and leads cross functional teams to assist business units in integrating quality into their strategic and operational plans.Evaluates and prioritizes recommendations for quality improvement to senior management and/or customers.Partners with sales and marketing across all segments in their efforts to acquire and retain customers (e.g. responding to RFPs), quality presentations, request for measurement information.Develops and implements the infrastructure of the QM program and Patient Safety strategy.
Direct Employer
Seeks and assures compliance with the conditions of Participation for Critical Access Hospitals. Leads the overall quality program according to the Quality Management Plan as well as peer review, utilization review and trauma reporting to meet State Health Department requirements. Coordination of patient care in the Swing Bed Unit in the absence of the Case Manager. Functions as Infection Control Coordinator.
Direct Employer
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. Schedule is Monday-Friday standard business hours. No nights, no weekends and no holidays! Must reside in Phoenix or Tucson metro area.Remote role mainly. Travel is 10% local travel in the Phoenix or Tucson, Arizona.The Quality Management Nurse Consultant 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 review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. 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 the 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.
Direct Employer
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. The quality management Nurse Consultant 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 review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. 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 the 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.
Direct Employer
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.Job responsibilities include but not limited to:-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 review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.-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 the 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.
Direct Employer
Participates in the development and ongoing implementation of QM Work Plan activities. Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives.Local travel is throughout Maricopa County, AZ up to 25%.Schedule is Monday-Friday standard business hours.No nights, no weekends and no holidays!No on call.Must reside within or 20 miles of Maricopa County.Job responsibilities include but not limited to:Completes a variety of Behavioral Health/ Integrated Care audits for all lines of business including AHCCCS, DES and DCS-CHPConducts exit interviews with clinical and leadership staff to review audit results Assists with developing performance improvement plansDevelops audit tools for all populationsTrack completion of performance improvement plansCompletes data entry on all audit toolsParticipates in completing inter rater reliability and scoring guidelines.Participates in QM meetings
Direct Employer
The quality management nurse will be 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.The post would be a typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. The candidate must also have effective communication skills, both verbal and written.
Direct Employer
This is a telework position that requires routine in-state travel up to 50% of the time; when traveling use of personal vehicle. Qualified candidates must have valid KY driver's license, proof of vehicle insurance, and reliable transportation. Travel could be statewide based on business needs. Travel to the Louisville office for meetings and training is also anticipated. Candidates must reside in KY; residency in the Louisville, Frankfort, Lexington area is preferred.This position is accountable for health care quality projects and initiatives through direction setting and leadership. Assimilates information to proactively develop quality activities aligned with company strategies and values. Links the quality management activities to business goals. Proactively builds strong teams and business relationships, both internally and externally. Serves as a resource and subject matter expert (SME) on aspects of the quality program to develop and influence business strategies.For the Kentucky SKY program, this position also includes, but not limited to, functions such as: Quality of care monitoring, HEDIS measure reporting, education and monitoring, risk score and persistency data, Trauma informed care training and education, Adverse Childhood Event training and education, HEERO (Helping Each other/Everyone Reach Out) education and training, and quality strategy for medically complex population.