Position Overview
Job Description: - Participates in the development and ongoing implementation of QM Work Plan activities.
- Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities: - 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.
- Responsible for th...