Aetna UM Clinical Consultant in Louisville, Kentucky
Req ID: 44151BR
The Utilization Management Clinical Consultant utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. In this role you will take initial reviews telephonically through a queue and review faxes from utilization staff or outpatient providers. You will have an opportunity to use your clinical skills, impact members and work with other departments!
You will apply critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services. 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.
3+ years clinical practice experience, e.g., hospital setting, alternative care setting or behavioral healthcare setting is required
Licensed independent Behavioral Health clinician in state of service OR a Registered Nurse (RN) with unrestricted state license with a specialty in Behavioral Health is required.
Managed care/behavioral utilization review experience preferred.
The minimum level of education desired for candidates in this position is a Master's degree.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is desired
Mental Health/Licensed Master Social Worker (LMSW) is desired
Mental Health/Licensed Professional Counselor is desired
Full time Telework after 6 months of training within the physical office.
ADDITIONAL JOB INFORMATION
The highest level of education desired for candidates in this position is a Master's degree.
LMSW, LPC or RN with Psychiatric Background would be examples of an independent licensed professional we are seeking.
Managed care/utilization review experience preferred.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
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 is key!
Strong computer skills are needed, including Microsoft office!
Typical office working environment with productivity and quality expectations
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