Aetna UM Nurse Consultant in Morrisville, North Carolina
Req ID: 43572BR
In the Utilization Management Nurse Consultant position you will review requests for inpatient medical services based on established guidelines and makes appropriate approval decisions or referrals to the medical director in a timely manner.
Fundamental Components include, but are not limited to:
-Utilizes clinical expertise and skills to assess, plan, implement, coordinate, monitor and evaluate the appropriateness and medical necessity of services being requested
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
Communicates with providers and other parties to coordinate care/treatment
Identifies members for referral opportunities to case management, disease management and other programs if indicated.
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
-Managed Care experience; preferred
-3-5 years of clinical experience; required
-Utilization Review Experience; plus
-Computer navigation experience; required
The minimum 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/Medical-Surgical Care/1-3 Years
Benefits Management/Interacting with Medical Professionals/ADVANCED
Option for telework will be evaluated after demonstrated competency in the role (completion of successful audits)
ADDITIONAL JOB INFORMATION
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