Job description

Title: Quality Management Nurse Consultant
Location: remote
Duration: 6 Months

Description:

• This employer requires all employees, temporary labor, consultants, and contractors to be fully vaccinated against COVID-19 by their start date (other date may be inserted if start date is not accurate), subject to approved medical or religious exemptions.

Duties

• 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 the necessity of provider requests, but applying national and state based criterion, thus conducting Medical Necessity Review. Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.-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

Experience

• 5 years of clinical experience required- Managed Care experience preferred

Position Summary

• 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 the necessity of provider requests, but applying national and state based criterion, thus conducting Medical Necessity Review. Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.-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

Education

• RN with current unrestricted state licensure

Job Type: Contract

Salary: $35.00 - $36.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• On call
• Weekend availability

Work Location: Remote

arclintfl.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, arclintfl.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, arclintfl.com is the ideal place to find your next job.