Aetna QM Nurse Consultant in Sunrise, Florida

Req ID: 43670BR

Candidate must work out of ANY Aetna USA office that is in commutable distance with the exception of PA offices.

POSITION SUMMARY:

The Quality Management Nurse Consultant is responsible for reviewing documentation and interpreting data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

Fundamental Components included but not limited to:

Responsible for reviewing documentation and interpreting data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider Oral Surgery requests. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.

BACKGROUND/EXPERIENCE:

-At least 1-2 years ofexperience assisting with Oral Surgery procedures is required

-Experience reviewing Insurance plans and benefits is preferred

-Requires an RN with unrestricted activelicense

EDUCATION:

The highest 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 desired

FUNCTIONAL EXPERIENCES:

Functional - Nursing/Clinical coverage and policies/1-3 Years

Functional - Nursing/Clinical claim review and coding/1-3 Years

Functional - Clinical / Medical/Precertification/1-3 Years

TECHNOLOGY EXPERIENCES:

Technical - Aetna Applications/Aetna Total clinical View/1-3 Years/End User

Technical - Aetna Applications/Active Health Interface/1-3 Years/End User

REQUIRED SKILLS:

Benefits Management/Understanding Clinical Impacts/ADVANCED

General Business/Applying Reasoned Judgment/ADVANCED

DESIRED SKILLS:

Benefits Management/Interacting with Medical Professionals/ADVANCED

Technology/Leveraging Technology/FOUNDATION

Telework Specifications::

Telework considered only for unique circumstances.

ADDITIONAL JOB INFORMATION:

We are looking for a nurse with Oral Surgery background to perform reviews for Oral Maxillofacial Surgical procedures.

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