Aetna QM Nurse Consultant in Bismarck, North Dakota

Req ID: 39109BR

This is an office based role in Bismarck, ND. Internals will remain working out of their current office or remain work at home if they are already telework.

POSITION SUMMARY

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.

Fundamental Components include but are not limited to:

  • 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

    BACKGROUND/EXPERIENCE

    Registered Nurse (RN) with 3-5 years of clinical experience required

    Computer literacy including Outlook, Internet Explore, Excel and Microsoft Word

    Ability to effectively participate in a multidisciplinary team including internal and external participants

    EDUCATION

    The minimum 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 EXPERIENCES

    Medical/Clinical claim review & coding/1-3 Years

    Clinical coverage and policies/1-3 Years

    Medical-Surgical Care/4-6 Years

    TECHNOLOGY EXPERIENCES

    Microsoft Outlook/1-3 Years/End User

    Aetna Total clinical View/1-3 Years/End User

    Microsoft Explorer/4-6 Years/End User

    REQUIRED SKILLS

    Benefits Management/Interacting with Medical Professionals

    Benefits Management/Understanding Clinical Impacts

    General Business/Applying Reasoned Judgment

    DESIRED SKILLS

    Leadership/Collaborating for Results

    Leadership/Driving a Culture of Compliance

    Telework Specifications:

    Considered only for current internal teleworkers (in any area)

    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