Aetna UM Nurse Consultant in San Antonio, Texas

Req ID: 52927BR

POSITION SUMMARY

This is an in-office position in San Antonio, TX.

Positions include Precertification, Concurrent Review, and Retro Review. 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 Washington Education Association 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

Fundamental Components:

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.

BACKGROUND/EXPERIENCE:

RN licensure required

5+ years clinical experience required

Utilization management experience preferred

Managed care experience preferred

EDUCATION

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

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse (RN) is required

FUNCTIONAL EXPERIENCES

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

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

Functional - Nursing/Discharge Planning/1+ Years

Functional - Nursing/Case Management/1-3 Years

TECHNOLOGY EXPERIENCES

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

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

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

Technical - Computer Operations/System and Console Operations/4+ Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Applying Reasoned Judgment/ADVANCED

Leadership/Collaborating for Results/ADVANCED

DESIRED SKILLS

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 Washington Education Association.

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