Nurse Consultant w/ Legal Experience in Greenwood Village, Colorado
DescriptionActiveHealth is a technology-driven health management company that combines proprietary technology and clinical knowledge. We provide information that enables doctors and patients to make more informed medical decisions. Our CareEngine technology is an interactive care management solution which administers more than 12,000,000 members nationwide. It is just one of our health management solutions.
The dedication of talented and caring health care professionals drives the delivery of high quality, cost effective products and services. They make it possible for members to get the right health care treatment for their needs and for Aetna to keep its competitive edge.
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. 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.
Prepares and completes QM documents based on interpretation and application of business requirements. Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements. Assists in the development and implementation of QM projects and activities.
This position can be located in any of the following locations: Rolling Meadows, IL Chantilly, VA Greenwood Village, CORequirementsThis position can be located in any of the following locations: Rolling Meadows, IL Chantilly, VA Greenwood Village, CO
This is not a telework opportunity.
Registered Nurse (RN) is required
3-5 years clinical and/or managed care experience in the healthcare industry.
Demonstrating Business and Industry Acumen Maximizing Healthcare Quality
Nursing: Clinical coverage and policies Nursing: Legal and benefit interpretation Project Management: Issue identification and analysis Project Management: Evaluating success/lessons learned
We conduct pre-employment drug and background testing. ActiveHealth Management does not permit the use of tobacco related products or drugs in the workplace. No agencies, please. ActiveHealth Management is an Equal Opportunity/Affirmative Action Employer. M/F/D/V
ActiveHealth Management is committed to maintaining an environment in which all employees are treated equitably and given the opportunity within the context of the business to achieve their potential. ActiveHealth’s Affirmative Action responsibilities extend to women, minorities, persons with disabilities and veterans. Company policy also provides for equal opportunity for qualified individuals regardless of race, color, sex, national origin, religion, age, disability, veteran status, sexual orientation, gender identity or marital status.
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