Job Description
Job Description
This role is open to telework anywhere in the US!
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 clinical editing, policy and coding standards.
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 (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. 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.
Required Qualifications
* 3-5+ years of clinical experience required
* RN with current unrestricted state licensure required-
* 1-3+ Years Clinical / Medical/Direct patient care experience (hospital, private practice) required
TECHNOLOGY EXPERIENCES:
* Technical - Remote Access/WAH (Work at Home)
* Technical - Computer Operations/System and Console Operations
REQUIRED SKILLS:
* Benefits Management/Interacting with Medical Professionals/ADVANCED
* Benefits Management/Understanding Clinical Impacts/ADVANCED
* General Business/Applying Reasoned Judgment/ADVANCED
Preferred Qualifications
* Managed Care experience preferred
* Certified Coder or coding experience preferred
* 1-3+ Years Medical/Clinical claim review & coding preferred
Education
Associate's degree or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
This role is open to telework anywhere in the US!
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 clinical editing, policy and coding standards.
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 (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. 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.
Required Qualifications
* 3-5+ years of clinical experience required
* RN with current unrestricted state licensure required-
* 1-3+ Years Clinical / Medical/Direct patient care experience (hospital, private practice) required
TECHNOLOGY EXPERIENCES:
* Technical - Remote Access/WAH (Work at Home)
* Technical - Computer Operations/System and Console Operations
REQUIRED SKILLS:
* Benefits Management/Interacting with Medical Professionals/ADVANCED
* Benefits Management/Understanding Clinical Impacts/ADVANCED
* General Business/Applying Reasoned Judgment/ADVANCED
Preferred Qualifications
* Managed Care experience preferred
* Certified Coder or coding experience preferred
* 1-3+ Years Medical/Clinical claim review & coding preferred
Education
Associate's degree or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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