**Required Qualifications:
-3+ years of clinical experience required
-RN with current unrestricted state licensure required,
- Compact license preferred or IL license
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.
Participates in the evaluation and interpretation of data to identify opportunities for improvement and interventions to improve PQOC process
Monday - Friday, 8AM to 5PM
