Aetna UM Clinical Consultant in Dallas, Texas
Req ID: 43482BR
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.
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
RN license required
3+ 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
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 - Nursing/Medical-Surgical Care/4+ Years
Functional - Clinical / Medical/Concurrent review / discharge planning/1+ Years
Functional - Medical Management/Medical Management - Concurrent Review/1+ Years
Functional - Customer Service/Customer Service - Member Services - HMO products/1+ Years
Technical - Aetna Applications/QNXT/1+ Years/End User
Technical - Desktop Tools/Microsoft Outlook/1+ Years/End User
Technical - Desktop Tools/Microsoft Word/1+ Years/End User
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