Aetna UM Nurse Consultant in Denver, Colorado

Req ID: 37010BR

We are seeking individuals that will be a strong contributor to our UM team.

POSITION SUMMARY

Telephonic Utilization Review nurse with RN degree. Ability to multi-task between telephonic reviews and data entry of clinical information.The nurse uses clinical skills to coordinate, document and communicate all aspects of the utilization management program. 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. Compact State or Arkansas RN license required.

Fundamental Components:

Perform Medical Necessity review for services requiring preauthorization. These services include but are not limited: to Inpatient, DME, Procedures, OP, IV infusion, Medications, Rehab, Skilled Nursing Facility, Substance abuse, IP and OP Mental Health. Issue notification of determination decisions related to concurrent review determinations. This includes communications to provider, hospital and Member. Meet specific job metrics related to audits scores and daily production.

*Confident in navigating multiple systems, multiple platforms, and being comfortable in switching between technology platforms

*Flexibility working in a rapidly changing environment as the program evolves and develops to meet our customers and members expectations (leveraging the same bullet from the above role)

*Manage multiple priorities and adapt in a fast paced environment. Being responsible for production and quality metrics.

*Confident in oral discussion with external providers to obtain and document clinical information

Direct providers and members toward in-network steerage

Gathers clinical information and applies the appropriate clinical guidelines. Policies and procedures clinical judgment to render medical necessity determination.

Adhere to all URAC accreditation guidelines and regulatory requirements

Interpret applicable criteria and guidelines while assessing benefits to ensure appropriate administration of those benefits to help support in the development of the members care

Collaborate with Medical Directors

Identify and make referrals to Case Management

Prioritize daily work lists to ensure the requests are completed timely

The role requirements will follow the core JVS Job description. Please review all requirement in the JVS job description on eservice

BACKGROUND/EXPERIENCE desired:

Managed Care experience preferred. 3-5 years of clinical experience required RN with current unrestricted state licensure required. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

EDUCATION

The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse (RN) is desired

Nursing/Certified Case Manager is desired

FUNCTIONAL EXPERIENCES

Functional - Nursing/Concurrent Review/discharge planning/4-6 Years

Functional - Nursing/Discharge Planning/4-6 Years

Functional - Nursing/Medical-Surgical Care/4-6 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User

Technical - Desktop Tools/Microsoft SharePoint/4-6 Years/End User

Technical - Desktop Tools/Microsoft Word/4-6 Years/End User

REQUIRED SKILLS

Benefits Management/Supporting Medical Practice/ADVANCED

General Business/Consulting for Solutions/FOUNDATION

Service/Providing Solutions to Constituent Needs/ADVANCED

Telework Specifications:

WAH available to staff currently working at home. New employees must be office based

ADDITIONAL JOB INFORMATION

we are seeking individuals that will be a strong contributor to our UM team

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Job Function: Health Care