Aetna UM Clinical Consultant 38753BR in Dallas, Texas

Req ID: 38753BR

POSITION SUMMARY

The candidate utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.

Fundamental Components:

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. Collaborates with interdisciplinary team during case rounds to facilitate services, discharge planning

BACKGROUND/EXPERIENCE desired:

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 preferred

EDUCATION

The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse (RN) is desired

FUNCTIONAL EXPERIENCES

Functional - Nursing/Concurrent Review/discharge planning/4-6 Years

Functional - Medical Management/Medical Management - Concurrent Review/1-3 Years

Functional - Clinical / Medical/Concurrent review / discharge planning/4-6 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User

ADDITIONAL JOB INFORMATION

Looking for a candidate with preferred managed care experience and a clinical background in behavioral health, obstetrics and gynecology, neonatal intensive unit and medical surgical. 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. The candidate will work in an in office cubical setting protecting the confidentiality of member information and adheres to company policies regarding confidentiality. The candidate should have effective communication skills, both verbal and written. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

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.

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Job Function: Health Care