Aetna Appeals Nurse Consultant in Hartford, Connecticut
Req ID: 43634BR
Exposure to a wide variety of clinical appeal issues.
Review post service Legacy Aetna and Legacy Coventry provider appeal requests.
Collaborate with Aetna medical directors.
Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins..
Become a subject matter expert with regard to the Centers for Medicare & Medicare Services Guidelines, Industry medical necessity guidelines of MCG and/or InterQual.
Contribute to Aetnas strong Medicare star quality ratings.
RN is required
3-5 years of clinical experience required
Strong written and verbal communication skills
Managed Care experience preferred
Medicare experience desired but not required
The minimum 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 required
Functional - Nursing/Critical Care/1+ Years
Functional - Nursing/Emergency Room/1+ Years
Functional - Nursing/Medical-Surgical Care/1+ Years
Functional - Nursing/Concurrent Review/discharge planning/1+ Years
Technical - Aetna Applications/Aetna Total clinical View/1+Years/
Technical - Aetna Applications/Aetna Strategic Desktop Reporting/1+ Years/
Technical - Aetna Applications/Complaints & Appeals Tracking System/1+ Years/
Benefits Management/Interacting with Medical Professionals/ADVANCED
Service/Creating a Differentiated Service Experience/FOUNDATION
Benefits Management/Understanding Clinical Impacts/ADVANCED
Leadership/Collaborating for Results/ADVANCED
Service/Handling Service Challenges/ADVANCED
This is a Full Time, Work at Home position. Must live within 1 hour to 1.5 hours of Aetna office and must be flexible to come into office location when needed
ADDITIONAL JOB INFORMATION
This full time position is part of a team of a number of Complaint and Appeal Nurse Analysts and Complaint and Appeal Consultants. Our team provides comprehensive post-service utilization management review for providers.
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