Under The Direction Of The RN Audit Manager, Perform Assigned Audits Of UM Procedures And Notes To Ensure Compliance With UM Standard Procedures. This May Also Include Review Of Medical Records Maintained In Support Of Precertification, Concurrent Evaluations, And Clinical Reports Submitted By Providers To Verify That Relevant Clinical Information Was Used To Make Decisions. The Incumbent Will Demonstrate Sound Clinical Judgment, Knowledge Of Usability Testing, And Product Value Proposition. The Candidate Must Understand/Be Familiar With The Regulatory And Credentialing Process Related To Medicaid Managed Care, Waste, Fraud And Abuse, And The Use Of Nationally Recognized Medical Needs Systems.

• Supports The Aetna Medicaid Clinical Philosophy And UM's Standard Service Model. Apply Evaluation Criteria To Determine Overall Compliance With UM Programs, Policies, And Procedures.
• Works Closely With Clinical Department Leaders To Ensure Consistency And Accuracy Of Clinical Decisions And Conform To All State Requirements. Reviewing Integrated Information Plans For Compliance With NCQA UM Standards
• Completes Assigned Samples In A Timely, Efficient, And Accurate Manner, Meeting All Identified Deadlines.
• Enter And Maintain All Required Data In The Selected Survey Tool As Provided. Identifies Opportunities To Implement Best Practices And Innovations To Improve Results And Strengthen Organizational Performance.
• He Is Responsible For Achieving The Mission And Quality Of The Team. Meets Performance Expectations And All Organizational Goals.
• Mindful Of Maintaining A High Level Of Service. Always Demonstrate The Ability To Serve As A Model Change Agent And Inform Change Efforts.
• Responsible For Maintaining Compliance With Policies And Procedures At The Employee Level.
• Participates In The Analysis And Interpretation Of Data To Identify Areas Of Opportunity For Improvement And Interventions To Improve Project Management Results.
• Working Knowledge Of Managed Care Concepts, Preferably Including Medicaid And/Or Medicare.
• Ability To Identify Deviations From Standard Operating Procedures/Plans
• Ability To Meet Deadlines And Take Responsibility For Accurate And Timely Delivery
• Excellent Interpersonal, Verbal, And Written Communication Skills
• Ability To Motivate Yourself And Thrive As A Team
• Use And Follow RN Review Procedures And Procedures
• Ability To Maximize Available Resources By Demonstrating Excellent Judgment And Team-Driven Behavior In Support Of Organizational Goals.
• Adaptation To A Rapidly Changing Environment
• Creative Problem-Solving Skills And Awareness Of Continuous Quality Improvement Concepts

Qualifications Required

• Must Live In Oklahoma
• Oklahoma Licensure Does Not Preclude Employment As A Registered Nurse Through The State Board Of Nursing
• 4+ Years Of Clinical Nursing Experience
• At Least 3 Years Of Experience In Usage Management, Pre-Licensed And/Or Temporary Audit
• At Least 3 Years Of Experience Translating And Implementing National Health Needs Systems (e.g. MCG And/Or Interqual) Is Required.
• At Least 2 Years Of Experience Using A Personal Computer, Keyboarding, Navigating Multiple Systems And Applications; And Using Applications From The MS Office Suite (Teams, Outlook, Word, Excel, Etc.)
• Be Willing And Able To Provide UM Call Coverage For Nights And Weekends On A Shift Basis As Required By State Regulatory Agencies.

Eligibility Of Candidates

• Managed Care Experience
• Medicaid And/Or Medicare Experience
• Familiarity With NCQA UM Standards Is A Plus

Job Benefits:

• Health Benefits: Because Aetna Is A Health Insurance Company, It Generally Offers Comprehensive Health Benefits, Including Health, Dental, And Vision Insurance, To Eligible Employees And Dependents.
• Wellness Programs: Aetna Promotes Employee Wellness Through A Variety Of Programs, Which May Include Exercise Groups, Health Challenges, And Resources To Maintain A Healthy Lifestyle.
• 401(K) Retirement Plan: Aetna May Offer A 401(K) Plan That Allows Employees To Save For Retirement Through Tax-Deductible Contributions. Some Companies Also Offer Matching Offers.
• Time Off (PTO): This Can Include Vacation Days, Sick Days, And Statutory Holidays, Allowing Employees To Take Time Off Work While Still Being Paid.
• Flexible Spending Accounts (FSA): These Accounts Allow Employees To Withdraw Pre-Tax Dollars To Cover Medical, Dental And Dependent Care Expenses.
• Life Insurance And Disability Insurance: Aetna Can Provide Life Insurance And Disability Insurance To Help Protect Employees And Their Families Financially.
• Employee Assistance Programs (Eaps): Eaps Provide Support For Personal And Employment Issues, Including Counseling, Legal Assistance, And Financial Planning.
• Professional Development: Aetna Can Provide Professional Development Opportunities Through Training, Courses, And Educational Resources.
• Parental Leave: Maternity And Paternity Leave To Support Employees When They Become Parents.
• Tuition Assistance: Some Companies, Including Aetna, Offer Tuition Reimbursement Or Assistance Programs To Help Employees Continue Their Education.
• Employee Discounts: Discounts On Aetna Health Insurance Plans And Other Potential Products And Services.
• Remote And Flexible Work: Depending On The Service, Aetna May Offer Flexible Work Arrangements Or Remote Work Options.