Oct 13, 2019
Aetna Description: Responsible for conducting audits of current processes, reports, and procedures to identify process improvements and issue resolutions. Develops and conducts medical management staff training based on outcomes of clinical audits. 65174 Fundamental Components: Provides ongoing and random qualitative and quantitative analysis of the business process, clinical systems, tools, and staff competencies using organizational performance measurements to ensure compliance with government regulations and corporate policy. Reviews and evaluates internal controls are in place to ensure ongoing compliance. Identifies, documents, and reports any transaction errors in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Recommends corrective action and facilitates the implementation of remedial and process improvement plans. Develops and conducts medical management staff training based on outcomes of clinical audits. Implements training programs to increase role specific consistencies and efficiencies related to process work flows. Measures outcomes of clinical staff training and identifies key findings to ensure effective alignment of training content and method of delivery with business objectives and staff performance requirements. Promotes continuing compliance with accreditation and/or applicable regulatory body requirements including but not limited to: company's ethical, fraud, abuse, and compliance policies and expectations, utilization management policies, procedures and workflows, key accreditation standards, and HIPAA regulatory standards related to use of PHI. Facilitates communication of relevant findings to corporate Compliance Department and/or Corporate Privacy/Security Officer. Performs other duties as required. Background Experience: Excellent verbal and written communication skills. Experience in designing, developing, and instructing training programs. Ability to use standard corporate software packages and corporate applications. Previous (3-5+ years) experience in a managed care clinical operations environment (case management and specialty programs) required. Strong data analysis and report preparation skills. A current clinical license in the state where job duties are performed is required based on the clinical sector supported and may include any of the following: RN.Required Additional Job Information: This is an exciting time to join the Training & Quality Clinician team. We are inspired to make a difference, and we are committed to integrity and clinical excellence. We strive to work together as a team to enhance the quality of services rendered by our staff. Required Skills: Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance, Technology - Leveraging Technology Desired Skills: General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Consulting for Solutions Functional Skills: Nursing - Case Management, Nursing - Discharge Planning, Nursing - Medical-Surgical Care Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Education: Nursing - Registered Nurse Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
Professional Diversity Network Blue Bell, PA, USA Full-Time