Aetna QM Nurse Consultant in Jacksonville, Florida

Req ID: 53503BR


This position is open to candidates across the country. Telework will only be considered for current internal teleworkers.

The Medicare Predetermination 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 specific to Medicare.

Fundamental Components:

  • Identification of Members/Services to be reviewed - Review and authorize the required services in accordance with the benefit plan and Medicare requirements - Assessment of Medical Documentation - Promotes communication, both internal and external, to enhance effectiveness of CCR reviews - Application 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 procedures - Consults with supervisors and/or Medical Directors as appropriate - Protects the confidentiality of member information and adheres to company policies regarding confidentiality


    Registered Nurse (RN) is required

    3+ years of clinical experience is required

    Clinical claim review experience is preferred

    Medicare experience is 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 required for candidates in this position is a Associate's degree or equivalent experience.


    Nursing/Registered Nurse is required


    Functional - Clinical / Medical/Concurrent review / discharge planning/1+ Years

    Functional - Nursing/Medical-Surgical Care/1+ Years

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


    Technical - Computer Operations/System and Console Operations/1+ Years/End User

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

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


    Benefits Management/Interacting with Medical Professionals/ADVANCED

    Benefits Management/Understanding Clinical Impacts/ADVANCED


    General Business/Demonstrating Business and Industry Acumen/ADVANCED

    Leadership/Collaborating for Results/ADVANCED

    Leadership/Driving a Culture of Compliance/FOUNDATION

    Telework Specifications:

    Considered only for current internal teleworkers (in any area)


    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