CVS Health A1A Quality Management Nurse Consultant in Chandler, Arizona
This role is part time telework and part time office based in Chandler, AZ, High Point, NC or New Albany, OH. Candidates must be able to commute to one of these locations.
What is A1A
Aetna One Advocate is Aetna’s premier service and clinical offering for Aetna nation-wide. A1A
creates industry-leading solutions for our customers and members. The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services. The mission of this model is designed to meet each member at every aspect of their health care journey. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members’ needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. This is an exciting time to join A1A and change the way healthcare is delivered today. We are health care innovators.
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. Responsible for group coaching, and 1:1 staff support across all A1A sites. Requires an RN with unrestricted active license.
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.
-3+ years of clinical experience required
-RN with current unrestricted state licensure required
-1+ year of managed care experience required
-2+ years of experience in coaching and mentoring peers and new employees required
-Utilization Review/Management and precert experience preferred
-Case Management experience preferred
Additional Job Information
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 Effective communication skills, both verbal and written.
Bachelor's degree or equivalent experience
Percent of Travel Required
0 - 10%
Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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