Aetna UM Nurse Consultant in Washington, District Of Columbia
Req ID: 44596BR
This position is open for telework in DC, MD or VA.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
Work hours will include weekend and weekday shifts.
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
Communicates with providers and other parties to facilitate care/treatment
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
1 year of Managed Care experience; preferred
3-5 years of clinical experience; required
Milliman (MCG) criteria application experience; preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is required
Functional - Nursing/Medical-Surgical Care/4-6 Years
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Medical Management/Medical Management - Managed Care/Insurance Administration/1-3 Years
Functional - Products-Medical/Miscellaneous Plans/1-3 Years
Technical - Computer Operations/System and Console Operations/4-6 Years/End User
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Aetna Applications/Aetna Total clinical View/1-3 Years/End User
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
General Business/Applying Reasoned Judgment/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
General Business/Consulting for Solutions/FOUNDATION
Leadership/Collaborating for Results/ADVANCED
Position will be full-time work at home at this time. This position is open for telework in DC, MD or VA. First day of work will be at the nearest Aetna office. All employees are subject to return to nearest office location if business needs change.
ADDITIONAL JOB INFORMATION
This job offers the use of nursing judgment and skills in a multitude of clinical scenarios.
The ability to work from home increases work-life balance.
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