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POSITION SUMMARY

This is a full-time remote opportunity. Working schedule is Monday through Friday, 8:00 AM -5:00 PM Eastern Standard Time (EST) with flexibility to work outside of business hours, as needed.
This position reports to the Potential Quality of Care (PQOC) nurse investigator team manager. This position is responsible for the review and evaluation of protected clinical information and documentation.
The PQOC team 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.
Applies specialized clinical knowledge to participate in quality improvement efforts to assess and enhance patient care. Collaborates with the healthcare quality team to collect and analyze clinical data, participate in quality reviews, and identify opportunities for process improvement. Provides insights and recommendations to optimize healthcare practices and promote patient safety and satisfaction.

Additional responsibilities to include but not limited to the following:

• Works Potential Quality of Care cases (Medical), along with Patient Safety Events across all lines of business (Commercial, Medicare, and Medicaid). 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 critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• This position 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.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Reports 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 as well as knowledge of internal systems.

Required Qualifications

• Registered Nurse (RN) with current unrestricted compact license and willing to obtain additional licensure as needed.
• 3 years of clinical experience required.
• 2 years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)

PREFERRED QUALIFICATIONS

• Emergency/critical care experience
• Experience working Grievance cases
• Case Management or Utilization Management experience
• Managed care experience
• Medicaid experience
• Systems experience: ATV, GPS, MedCompass, QNXT, Dynamo, MedHok
• Critical thinking skills
• Previous experience working in a remote/virtual environment
• Preference for those in EST or CST zones.
• Bachelor’s of Science in Nursing

EDUCATION

Associates or Diploma nursing degree required.

• Works Potential Quality of Care cases (Medical), along with Patient Safety Events across all lines of business (Commercial, Medicare, and Medicaid). 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 critical thinking skills in addition with team based decision rubric to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• This position 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.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Reports 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 as well as knowledge of internal systems