Registered Nurse ( RN ) - Quality Management ( QM )
5 - 7 years experience • Managed Care & Health Insurance
The Site Review Nurse Consultant position is responsible for the review and evaluation of clinical information and documentation and QM FSR(Facility Site Reviews).
In this role you will review documentation and interpret 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.
This role independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.
This is an exciting opportunity to become part of a brand new plan and become certified in site review if you are not already! Outside of the 75% local travel this role will be IN OFFICE in West Sacramento.
-Conducts audits on network offices-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.
- Managed Care experience is preferred.
- 3-5 years of clinical experiencerequired.
- RN with current unrestricted state licensure required.
- Certified Site Reviewer would be a huge plus!
- HEDIS experience is a plus!
- Position requires proficiency with MS Office Suite and navigating multiple systems and keyboarding Effective communication skills, both verbal and written.
- Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
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