Aetna UM Nurse Consultant in Hartford, Connecticut
Req ID: 41599BR
As a Utilization Management (UM) Nurse Consultant, you will utilize 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 include, but are not limited to:
-Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
-Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
-Identifies members who may benefit from care management programs and facilitates referral Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
-Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
Managed Care experience preferred 3-5 years of clinical experience required e.g., hospital setting, alternative care setting such as home health or ambulatory care required
Registered nurse (RN) with unrestricted state license.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
The highest 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 - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Medical-Surgical Care/4-6 Years
Functional - Nursing/Home Health Care Ambulatory Nursing/1-3 Years
Functional - Nursing/Discharge Planning/1-3 Years
Functional - Nursing/Critical Care/1-3 Years
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
General Business/Turning Data into Information/FOUNDATION
Benefits Management/Supporting Medical Practice/ADVANCED
General Business/Consulting for Solutions/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
One UMNC will support the New England market. (position may be office based with ability to become telework)
One UMNC will support the New Jersey market. (No office in New Jersey to support office based nurse so the New Jersey nurse will be telework)
ADDITIONAL JOB INFORMATION
Full-Time Telework (WAH). May need to attend in office meetings/trainings as needed.
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