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Description

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Works Potential Quality of Care cases across all lines of business (Commercial and Medicare). 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 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. The incumbent must demonstrate strong clinical judgement, knowledge of internal systems.

Completes assigned PQOC investigations in a timely, efficient and accurate manner, meeting all turnaround times
Enters and maintains all required data elements into QM Issues Database, as directed
Identifies opportunities to implement best practice approaches and innovations to improve outcomes and enhance organizational efficiency
Meets all performance expectations and organizational goals. Mindfully sustains a high level of accountability
Consistently demonstrates the ability to serve as model for change and is accountable for maintaining compliance with policies and procedures at the employee level
Participates in the evaluation and interpretation of data to identify opportunities for improvement and interventions to improve PQOC process

Required Qualifications:
-3+ years of clinical experience required
-RN with current unrestricted state licensure required,
- Compact license preferred

Preferred Qualifications:
-Managed Care experienced preferred
-Utilization Management or Case
-- Management experience
-Critical thinking skills