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.

POSITION SUMMARY

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.

Fundamental Components:

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

BACKGROUND/EXPERIENCE desired:

Managed Care experience preferred

3-5 years of clinical experience required

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 required

FUNCTIONAL EXPERIENCES

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

TECHNOLOGY EXPERIENCES

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

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Benefits Management/Maximizing Healthcare Quality/FOUNDATION

Technology/Leveraging Technology/FOUNDATION

DESIRED SKILLS

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 ?

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.

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Job Function: Health Care