Sr Clinical Strategist - Aetna MPPS DRG Initiatives- RN
About the position Responsibilities • Conduct quality assessment (QA) clinical reviews and provide input for Medical Policy implementation of DRG initiatives, determining ROI and annual review processes • Lead and support SAI (scorable action items) projects; responsible for strategic ideation of resources and effective solutions for project development • Support Provider exceptions, legislative and regulatory requirements, and manage system and reporting tools, including AI, such as predictive modeling and quality audit • Determine medical necessity and appropriateness (may include prospective, concurrent, retrospective review/analysis of program submissions, claims) • Participate in the development, implementation, and evaluation of new claim edits, workflows and clinical programs • Monitor existing clinical programs and processes and ensure any changes and updates are successfully implemented • Perform root cause analytics from clinical, coding, and claim systems perspectives to identify efficiencies and improvements, and initiate changes in workflows • Render opinions on emerging clinical and coding trends, utilization and network management, plan coverage, and claims policy to develop medical cost containment solutions that meet business needs • Coordinate/Communicate with constituents to facilitate program optimization • Support member / provider experience and collaborate for improvement on NPS (Net Promotor Score) • Validate proposed medical cost containment ideas that may be managed as scoreable action items (SAIs) Requirements • Active and unrestricted Registered Nursing license in state of residence • 3 years Clinical Claim Review background in Commercial, Medicare, or IFP claims in a managed care organization (e.g. UM Nurse, Strategist) • Must have an understanding of clinical claim review • Demonstrated experience in project management including a foundational understanding of project management principles as applied within a managed care or healthcare delivery setting • Proven track record in meeting project milestones and negotiating for resources • Effective verbal and written communication • Ability to work independently as well as collaborate with colleagues from across organization • Proficiency in Microsoft Office Suite applications including Excel, Word, and Outlook Nice-to-haves • Technical/professional clinical expertise and experience relevant to business area • Working knowledge of MPPS programs, including Payment Policies, Precertification and Clinical Claim Review (CCR) • Understanding of Medicaid Health Plans, Aetna's standard contracts and provider contracting methodologies • Working knowledge of claim systems preferred • Understanding of clinical editing concepts (Ex: Program Integrity, Code Edit Third Party Vendors) Benefits • Affordable medical plan options • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility