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*Quality Management Nurse Consultant

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*Quality Management Nurse Consultant

  • Location:


  • Sector:

    MRS Nursing

  • Job type:

    Temporary & Contract

  • Salary:


  • Contact:

    April Arnado

  • Contact email:

  • Job ref:


  • Published:

    14 days ago

  • Expiry date:


  • Client:

    Medical Recruitment Strategies

**Fully Remote- WFH anywhere in the US

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs

Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

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 regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license

- 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 a case is reviewed by a practitioner with clinical expertise for the issue at hand.

-Commands a comprehensive knowledge of complex delegation arrangements, contracts ,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.


  • UTILIZATION MANAGEMENT experience, inpatient utilization management review pref. knowledge of Milliman/MCG
  • 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG
  • 3+ years of experience as an RN
  • 1+ year of inpatient hospital experience, specifically Med/Surg
  • Active and unrestricted RN licensure in state of residence
  • Able to work in multiple IT platforms/systems

Shift: Monday-Friday 8 am- 5:00 pm Eastern Standard Time

Job Period: 03/2023 to 06/03/2023