Aetna Appeals Nurse Consultant in Hartford, Connecticut

Req ID: 43634BR

POSITION SUMMARY

Exposure to a wide variety of clinical appeal issues.

Review post service Legacy Aetna and Legacy Coventry provider appeal requests.

Collaborate with Aetna medical directors.

Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins..

Fundamental Components:

Become a subject matter expert with regard to the Centers for Medicare & Medicare Services Guidelines, Industry medical necessity guidelines of MCG and/or InterQual.

Contribute to Aetnas strong Medicare star quality ratings.

BACKGROUND/EXPERIENCE desired:

RN is required

3-5 years of clinical experience required

Strong written and verbal communication skills

Managed Care experience preferred

Medicare experience desired but not required

EDUCATION

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

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse (RN) is required

FUNCTIONAL EXPERIENCES

Functional - Nursing/Critical Care/1+ Years

Functional - Nursing/Emergency Room/1+ Years

Functional - Nursing/Medical-Surgical Care/1+ Years

Functional - Nursing/Concurrent Review/discharge planning/1+ Years

TECHNOLOGY EXPERIENCES

Technical - Aetna Applications/Aetna Total clinical View/1+Years/

Technical - Aetna Applications/Aetna Strategic Desktop Reporting/1+ Years/

Technical - Aetna Applications/Complaints & Appeals Tracking System/1+ Years/

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Technology/Leveraging Technology/FOUNDATION

Service/Creating a Differentiated Service Experience/FOUNDATION

DESIRED SKILLS

Benefits Management/Understanding Clinical Impacts/ADVANCED

Leadership/Collaborating for Results/ADVANCED

Service/Handling Service Challenges/ADVANCED

Telework Specifications:

This is a Full Time, Work at Home position. Must live within 1 hour to 1.5 hours of Aetna office and must be flexible to come into office location when needed

ADDITIONAL JOB INFORMATION

This full time position is part of a team of a number of Complaint and Appeal Nurse Analysts and Complaint and Appeal Consultants. Our team provides comprehensive post-service utilization management review for providers.

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