Aetna UM Nurse Consultant in Denver, Colorado
Req ID: 37010BR
We are seeking individuals that will be a strong contributor to our UM team.
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.
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
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.
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 - Nursing/Concurrent Review/discharge planning/4-6 Years
Functional - Nursing/Discharge Planning/4-6 Years
Functional - Nursing/Medical-Surgical Care/4-6 Years
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
Benefits Management/Supporting Medical Practice/ADVANCED
General Business/Consulting for Solutions/FOUNDATION
Service/Providing Solutions to Constituent Needs/ADVANCED
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