Aetna UM Clinical Consultant in Moon township, Pennsylvania
Req ID: 39083BR
Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits in the prior authorization setting. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness.
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare
services/benefits for members in the prior authorization setting
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along
the continuum of care
Communicates with providers, medical directors and other parties to facilitate medically necessary care/treatment
Identifies members for referral opportunities to integrate with other products, services and/or programs
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
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 preferred
Must be proficient with computers and be able to quickly navigate multiple internet applications
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 is Required
ADDITIONAL JOB INFORMATION
Become part of an innovative and collaborative team that assists in ensuring that members have access to the care they need at the right time and in the right setting.
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