Managed Staffing, Inc. – HEDIS Quality Management Nurse
- Care Management Telehealth
- Posted 3 days ago
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Job Detail
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Job ID 3334
Job Description
Job Title: HEDIS Quality Management Specialist/Nurse
Location: Remote (All over USA)
Experience: 3 years of clinical experience required, Managed Care/Medicare experience preferred
Education: RN with current unrestricted state licensure
Work Schedule: M-F 8-5 (Training hours may vary)
Position Summary: As an HEDIS Quality Management Specialist, you will be responsible for the review and evaluation of clinical information and documentation. This involves interpreting data obtained from clinical records or systems to apply appropriate clinical criteria and policies in accordance with regulatory and accreditation requirements for member and/or provider issues. The role requires independent coordination of clinical resolutions with internal/external clinician support as needed.
Duties
- Review documentation and evaluate potential quality of care issues based on clinical policies and benefit determinations.
- Consider all documented system information and additional records/data to develop determinations or recommendations.
- Gather data through navigation of multiple system applications.
- Contact providers, vendors, or internal Aetna departments to obtain additional information.
- Accurately apply review requirements to ensure cases are reviewed by practitioners with clinical expertise.
- Command comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, and company policies.
- Proactively apply regulatory and accreditation standards to assure activities are reviewed and processed within guidelines.
- Condense complex information into a clear and precise clinical picture while working independently.
Required Experience
- 3 years of clinical experience required, with Managed Care/Medicare experience preferred.
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