Aetna UM Nurse Consultant in Sunrise, Florida

Req ID: 40933BR


Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.

This position will be Work-At-Home after a training period of approximately three months in the office.

Fundamental components include, but are not limited to:

  • Utilizes clinical experience and skills in a collaborative process to assess, 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.

  • Uses clinical judgment to make appropriate decisions; escalates issues as appropriate.

  • Maintains clinical knowledge by staying current on clinical advances and issues.

  • Leverages health information technology to drive healthcare quality outcomes.

  • Identifies members for referral opportunities to integrate with other products, services and/or programs.

  • 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.

  • Adhere to quality standards and guidelines.

  • Work in compliance with Aetna Better Health policies and procedures.

  • Effectively access relevant information.

  • Demonstrate critical thinking.

  • Uncover and respond to internal and external customer's needs.

  • Promote cross functional communication.

  • Demonstrate cross-culture sensitivity.

  • Find solutions to atypical or complex member issues.

  • Understand the various state, federal and regulatory agencies that evaluate health plan compliance and quality and the purpose and intent of each.

  • Operates within Aetna's Code of Conduct.

  • Handles set-up and troubleshooting for appropriate services and products impacting member discharge.

    Qualification Requirements:

  • Minimum of 3-5 years of clinical bedside nursing experience required.

  • Flexibility to be on call every 5th weekend required.

  • Active, unrestricted RN License for the State of Florida required.

    Preferred Skills and Experience:

  • Managed Care experience preferred.

  • Concurrent Review nursing experience preferred.


    The minimum level of education preferred for candidates in this position is a Bachelor's degree or equivalent experience.

    Licenses and Certifications:

  • Active, unrestricted Registered Nurse (RN) License for the State of Florida is required.

  • Certified Case Manager (CCM) is preferred.


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

    Functional - Nursing/Case Management/1-3 Years

    Functional - Nursing/Clinical coverage and policies/1-3 Years

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


    Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

    Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User

    Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

    Technical - Desktop Tools/Microsoft Word/1-3 Years/End User


    Leadership/Driving a Culture of Compliance/FOUNDATION

    Benefits Management/Interacting with Medical Professionals/ADVANCED

    General Business/Applying Reasoned Judgment/ADVANCED


    Service/Providing Solutions to Constituent Needs/ADVANCED

    Benefits Management/Maximizing Healthcare Quality/FOUNDATION

    Leadership/Collaborating for Results/ADVANCED


    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