Aetna Utilization Management Nurse Consultant in Phoenix, Arizona

Req ID: 45154BR

POSITION SUMMARY

Utilizes clinical skills to support the coordination, documentation and communication all aspect of the Concurrent Review benefit program for Medicaid populations. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate prior authorization of services

Fundamental Components:

Utilizes clinical experience and skills in a collaborative process to asses, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. 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 facilitate care/treatment. Performs medical necessity reviews for requests requiring initial and concurrent review for inpatient hospitalization. Presents clear and accurate documentation that demonstrates proper application of clinical criteria. Collaborates with staff to ensure timely and accurate processing of authorization request Utilize critical thinking skills and judgment for making medical necessity determination for prior authorization process. Participates in after hours on-call rotation.

BACKGROUND/EXPERIENCE required:

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 preferred. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Requires Associate's degree or equivalent experience, RN Licensed in the state of AZ.

EDUCATION

The highest level of education required 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 - Medical Management/Medical Management - Concurrent Review/1-3 Years

Functional - Medical Management/Medical Management - Discharge planning/1-3 Years

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

Functional - Medical Management/Medical Management - Case Management/1-3 Years

Functional - Nursing/Concurrent Review/discharge planning/1-3 Years

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.

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