Aetna Appeals Nurse Consultant in Sacramento, California

Req ID: 45501BR

POSITION SUMMARY

Review clinical appeals related to Medicare Advantage Plan members using Center for Medicare and Medicaid Services criteria as well as other criteria

Fundamental Components:

Review clinical appeals concerning a variety of clinical areas e.g. SNF, radiology, DME

Make recommendations to Medical Directors

Consult with Medicare coverage guidelines, Clinical Policy Bulletins and MCG

**Looking for experience UR nurse on west coast if possible or if located in other areas to work later shift

This is a full time position and could have a work schedule Wednesday-Sunday or Friday-Tuesday

Would be a plus for anyone who is willing to work every weekend

BACKGROUND/EXPERIENCE:

3-5 years of clinical experience required

Managed Care experience preferred

3-5 years Utilization Review experience preferred

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 - Nursing/Concurrent Review/discharge planning/4-6 Years

Functional - Nursing/Medical-Surgical Care/4-6 Years

REQUIRED SKILLS

Service/Creating a Differentiated Service Experience/FOUNDATION

Technology/Leveraging Technology/FOUNDATION

DESIRED SKILLS

Leadership/Driving a Culture of Compliance/FOUNDATION

ADDITIONAL JOB INFORMATION

An opportunity to work with a dynamic team utilizing your clinical experience.

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