Aetna Appeals Nurse Consultant in Atlanta, Georgia

Req ID: 37732BR

POSITION SUMMARY

Responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

Fundamental Components:

3-5 years of clinical experience and concurrent unrestricted State licensure (RN). Must be computer literate to navigate through internal and external computer systems. Outstanding interpersonal & negotiation skills to effectively establish positive relationships with all constituents both internal and externally. Must be able to exercise independent and sound judgment in clinical decision making. Strong verbal & written communication skills. Organizational skills, effective time management and ability to manage multiple priorities are a must. Managed care or utilization management experience preferred.

BACKGROUND/EXPERIENCE desired:

Managed Care experience preferred

3-5 years of clinical experience required

EDUCATION

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 license is required

FUNCTIONAL EXPERIENCES

Functional - Nursing/Medical-Surgical Care/1-3 Years

Functional - Nursing/Concurrent Review/discharge planning/1-3 Years

Functional - Nursing/Clinical coverage and policies/1-3 Years

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

Technology/Leveraging Technology/FOUNDATION

DESIRED SKILLS

Leadership/Collaborating for Results/ADVANCED

Telework Specifications:

Telework will be considered for current internal teleworkers and option for telework will be evaluated after a minimum of one year of employment for in office and external candidates.

ADDITIONAL JOB INFORMATION

Dynamic fast paced team which reviews clinical appeals issues across different clinical skill competencies (i.e. Medical/ Surgical; Critical Care; Outpatient Services; Womens Health)

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.

Job Function: Health Care