Aetna QM Nurse Consultant in Allentown, Pennsylvania
Req ID: 43672BR
This opportunity is open to any Aetna Office!
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.
Review and authorize the required services in accordance with the benefit plan and clinical policy 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) required 3-5 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 highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is required
Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years
Functional - Clinical / Medical/FE Clinical coverage & policies/1-3 Years
Functional - Nursing/Medical-Surgical Care/4-6 Years
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Technical - Aetna Applications/Aetna Total clinical View/4-6 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
This is an office-based position. Option for telework could possibly be evaluated after a certain period of employment, in accordance with department policy. Internal candidates will remain working out of their current office or remain work at home if they are already telework.
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.
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 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 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