Aetna UM Nurse Consultant in Blue Bell, Pennsylvania
Req ID: 40874BR
This role is work at home in California. The hours are Monday-Friday with the possibility of working weekends as required.
This position is for CCMU/Towers exchange membership. Position requires utilization of clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license. We are looking for a Utilization Management Nurse Consultant to join the New Albany Dedicated Unit. In the Utilization Management Nurse Consultant role we are looking for a candidate who will be able to utilize 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. The UMNC will gather clinical information and apply the appropriate clinical criteria, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. The UMNC communicates with providers and other parties to facilitate care/treatment and lends expertise to other internal and external constituents in the coordination and administration of the utilization management function. UMNC will work collaboratively with the other members of the care advocate team.
The Utilization Nurse Consultant is an integral member of the care management team. Utilizing clinical skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options and services to facilitate appropriate inpatient healthcare management and effective discharge planning to improve the outcomes for members. More specifically, the inpatient care process includes: obtaining necessary information from providers and facilities; assessment of a member's clinical condition and ongoing medical services and treatments to determine medical appropriateness; guide the setting for medical intervention to achieve optimum length of stay for members. Authorize and coordinate the required services, in accordance with the benefit plan. Determines appropriate levels of coverage for inpatient stay by using clinical judgment and applying Milliman Care Guidelines, or Interqual Criteria to meet the member's needs. Evaluates, periodically, the member's progress in meeting the inpatient care plan and discharge goals, and revises and coordinates plan with the hospital discharge planner, the attending physician, and the patient/family when appropriate. Develop approach to removing barriers and use UR departments to facilitate adherence to care plan
Managed Care experience preferred
3-5 years of clinical experience required
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 required
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Medical-Surgical Care/1-3 Years
Functional - Nursing/Home Health Care Ambulatory Nursing/1-3 Years
Technical - Aetna Applications/Aetna Total clinical View/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Benefits Management/Interacting with Medical Professionals/ADVANCED
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
Benefits Management/Supporting Medical Practice/ADVANCED
Leadership/Collaborating for Results/ADVANCED
ADDITIONAL JOB INFORMATION
The candidate has the ability to exercise independent and sound judgment, has strong decision-making skills and well-developed interpersonal skills. Ability to manage multiple priorities, effective organizational and time management skills along with strong teamwork skills. Managed Care experience and prior experience within a telephonic customer service center type of environment is preferred. Candidate must possess good computer skills. Hours of operation are 8:00 AM to ?
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Job Function: Health Care