Description: 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.
Fundamental Components: Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers 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(*)
Background Experience: Managed care/utilization review experience; Preferred 1+ years clinical practice experience in Pediatrics, Labor and Deliver, Mother/Baby, or Obstetrics, e.g., hospital setting, alternative care setting such as home health or ambulatory care; Required. Registered Nurse (RN) with unrestricted state license; Required
Additional Job Information: Potential for telework available after successful completion or training Typical office working environment with productivity and quality expectationsWork requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Required Skills: Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment
Desired Skills: Leadership - Collaborating for Results
Functional Skills: Nursing - Concurrent Review/discharge planning, Nursing - Discharge Planning, Nursing - Emergency Room, Nursing - Maternal and Infant care, Nursing - Neonatal Intensive Care
Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word
Education: Nursing - Registered Nurse
Potential Telework Position: No
Percent of Travel Required: 0 - 10%
EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer
Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Candidate Privacy Information: 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
Internal Number: 62184BR
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