Aetna UM Clinical Consultant in Baton Rouge, Louisiana
Req ID: 38061BR
The Concurrent Review RN 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.
-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 strongly preferred. Registered Nurse (RN) with unrestricted LA state license.
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
Medical Management/Medical Management - Concurrent Review/1-3 Years
Option for telework will be evaluated after a certain period of employment
ADDITIONAL JOB INFORMATION
Experience and knowledge required in clinical guidelines, systems and tools i.e., Milliman, Interqual, Knowledge of provider networks and delivery, ability to interface with providers Possesses sound clinical judgment Strong organizational skills with an attention to detail Ability to work independently and on a team Ability to work with all levels of management Strong documentation skills and broad based clinical knowledge Behavioral health and physical health integrated care experience Positions may require working on-site Self-motivated and confident making clinical decisions, ability to influence and shape clinical outcomes Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding 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 environment Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations. Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Louisiana is looking for people like you who value excellence, integrity, caring and innovation. As an employee, youll join a caring team dedicated to improving the lives of the most vulnerable in our population. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Louisiana, and we will support you all the way.
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