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.
*Quality Management Nurse Consultant
- Sector: MRS Nursing
- Contact: Marie Nellas
- Duration: 3 months
- Start Date: ASAP
- Client: Medical Recruitment Strategies
- Location: Woonsocket, United States of America
- Salary: Negotiable
- Expiry Date: 19 January 2023
- Job Ref: BBBH408454_1670363730
- Contact Email: mnellas@medicalrecruitmentstrategies.com