Aetna UM Clinical Consultant in Chicago, Illinois

Req ID: 41126BR

POSITION SUMMARY

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.

Fundamental Components:

Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services. Will be the lead NOA Reviewer determining appropriateness of NOA documentation. Will work with non-clinical and clinical staff on the appropriate denial documentation. Will follow CMS, state, and NCQA guidelines when reviewing and assisting with audits. Identifies opportunities to promote quality documentation and compliance with notification of non-certification process. Will assist in completing clinical case audits and provide the management team feedback.

BACKGROUND/EXPERIENCE desired:

3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

Managed care/utilization review 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/Nursing License is desired

FUNCTIONAL EXPERIENCES

Functional - Clinical / Medical/Concurrent review / discharge planning/1-3 Years

Functional - Administration / Operations/Data Entry/4-6 Years

TECHNOLOGY EXPERIENCES

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

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

ADDITIONAL JOB INFORMATION

Will need to be flexible with work schedule to accommodate high volume work. Able to multi-task and prioritize work. Will need to be in the office for on-site training. Computer skills is needed since documentation is done through use of various systems.

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.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Health Care