Aetna Concurrent Review Consultant (NV MCD) in Las Vegas, Nevada
Req ID: 42559BR
This is an office based role in Las Vegas, NV.
The Concurrent Review Consultant 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.
Fundamental Components include but are not limited to:
-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
-Positions may require working on a telephone queue or on-site visitation
-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.
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.
One of the following is required: (RN) with unrestricted NV state license or NV Licensed independent behavioral health clinician (e.g. LCSW, LPC, LMFT, PhD, or Psy.D) with NV state license.
Proficiency with MS Office Suite is required
Experience and knowledge required in clinical guidelines, systems/tools i.e., Milliman, Interqual is required
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
The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
ADDITIONAL JOB INFORMATION
Aetna Better Health of Nevada is looking for people like you who value excellence, integrity, caring and innovation. As an employee, youll join a 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 Nevada, 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. We give special attention to vulnerable populations, and require a level of cultural competence from all employees in an effort to solve for the needs of Medicaid members and to connect special populations to the unique resources they need to live healthier lives. We prioritize member connections in response to each member s cultural values and preferences. 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