Aetna Clinical Claim Review Nurse Co in Bismarck, North Dakota

Req ID: 54167BR


External & internal candidates will be located in Bismarck - ND, Arlington - TX, Houston - TX, New Albany - OH offices. Telework considered for internal candidates working from home only.

The Clinical Claim Review (CCR) process provides a clinical review to determine reimbursement for selected services. In addition the Nurse Consultant acts as a clinical resource for the customer service and claims processing areas.

Fundamental Components:

Identification of Members/Services to be reviewedReview and authorize the required services in accordance with the benefit plan and clinical policyAssessment of Medical DocumentationPromotes communication, both internal and external, to enhance effectiveness of CCR reviewsApplication and/or interpretation of appropriate clinical criteria and guidelines to reviews Maintaining compliance with various state and federal laws and regulations, where applicable, while adhering to company policy and proceduresConsults with supervisors and/or Medical Directors as appropriate


Registered Nurse (RN) with 3+ years of clinical experience required

Managed Care experience preferred Computer literacy including Outlook, Internet Explore, Excel and Microsoft Word

Ability to effectively participate in a multidisciplinary team including internal and external participants


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


Nursing/Registered Nurse is required


Functional - Clinical / Medical/Clinical claim review & coding/1+ Years

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

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


Technical - Aetna Applications/Aetna Total clinical View/1+ Years/End User

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

Technical - Desktop Tools/Microsoft Explorer/4+ Years/End User


Benefits Management/Interacting with Medical Professionals/ADVANCED

Benefits Management/Understanding Clinical Impacts/ADVANCED

General Business/Applying Reasoned Judgment/ADVANCED


Leadership/Collaborating for Results/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

Telework Specifications:

Considered only for current internal teleworkers (in any area)

Internal applicants in the Bismarck, Arlington, Houston, and New Albany offices


Open communication and collaboration with other departments at Aetna. Philosophy is to do the right thing for the right reasons. We do our very best to be flexible with our time in order to meet a work/life balance. Being a clinical team, we do embrace wellness and empower our employees to be a champion for themselves and others.

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 candidates'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

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.