Aetna FL MCD UM Nurse Consultant in Sunrise, Florida
Req ID: 53787BR
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. The UM Clinical Consultant utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services. This position may perform Concurrent Review and/or Prior Authorization job duties.
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support) Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
Identifies members who may benefit from care management programs and facilitates referral
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Managed care/utilization review experience preferred
Proficiency with computer skills, which includes Microsoft Office suite, navigating multiple systems and keyboarding is required.
Experience and knowledge required in clinical guidelines, systems/tools i.e., Milliman, Interqual. LCDs/MCSs, LOCUS, CASII, ASAM.
Strong documentation skills and broad based clinical knowledge is required.
Self-motivated and confident making clinical decisions; ability to influence and shape clinical outcomes.
Strong organizational skills with an attention to detail.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Additional Job Information:
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. 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.
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.
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.