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Job Description:
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.

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, 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.