Aetna Utilization Management Nurse Consultant in San Antonio, Texas
Req ID: 45620BR
This is an office based role in San Antonio, TX.
Positions include Precertification, Concurrent Review, and Retro Review. Must be Texas Based as required by the Plan. This position requires an RN with an unrestricted active license. The Utilization Manager gathers clinical information, applies appropriate clinical criteria/guidelines, policies, procedures, uses clinical judgment to render coverage determinations/recommendations along the continuum of care and communicates with providers and other parties to facilitate care/treatment. You will identify members for referral opportunities to integrate with other products, services and/or programs and opportunities in order to promote quality effectiveness of Healthcare Services and effective benefit utilization. In addition, as a UM Nurse Consultant you will utilize your clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program including but not limited to; precertification, pre determination, concurrent review, retro review, and discharge planning activities of the TRS members. This is a telephonic position which involves sitting for extended periods, talking on the telephone and typing on the computer. Typical business working environment with productivity and quality expectations.
UM Nurse Consultants require:
Effective communication skills, both verbal and written, and the ability to effectively and credibly discuss routine and complex care situations with both external and internal clinicians.
Intellectual humility, empathy, integrity, courage, and confidence to drive fair and purposeful and appropriate decisions.
The ability to prioritize and effectively adapt to a fast paced changing environment.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
An RN license is required
Managed Care experience preferred
3-5 years of clinical 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 is required
Functional - Medical Management/Medical Management - Managed Care/Insurance Clinical Staff/1-3 Years
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Discharge Planning/1-3 Years
Functional - Nursing/Case Management/1-3 Years
Functional - Nursing/Concurrent Review/discharge planning/4-6 Years
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Desktop Tools/Microsoft Explorer/4-6 Years/End User
Technical - Computer Operations/System and Console Operations/4-6 Years/End User
Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
Leadership/Collaborating for Results/ADVANCED
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
Service/Providing Solutions to Constituent Needs/ADVANCED
ADDITIONAL JOB INFORMATION
This is a fast paced unit with participants who often have complex nursing needs. Our UMNCs must be able to work efficiently with providers, participants, and families to determine gaps in medical care and be able to assist in comprehensive discharge planning. This is a team dedicated to the plan sponsor TRS, as part of the Arlington and San Antonio Customer Care Unit.
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