Aetna Registered Nurse (RN) - Utilization Management Nurse Consultant in Sunrise, Florida

Req ID: 37991BR

POSITION SUMMARY

The Utilization Nurse Consultant facilitates the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. In this role you will develop, implement and support Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. The services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. You will work daily with your team including your Medical Director to determine approvals and denials.

This is an in office opportunity to work with a team that loves their job and works well together! This will be in the Sunrise, FL office.

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.

Fundamental Components

  • 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

  • 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 and other parties to facilitate care/treatment

  • Effectively and credibly discusses routine care situations with clinicians

  • Uses clinical judgment to make appropriate accommodations; escalates issues as appropriate

  • Maintains clinical knowledge by staying current on clinical advances and issues

  • 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

  • Rigorously adheres to Aetna's code of conduct and compliance standards, and applicable laws and regulations

  • Effectively utilizes basic functionality of Aetna's standard office technology tools in day-to-day work

  • Integrates technology applications in day-to-day work to improve efficiency and effectiveness

  • Able to explain the plan, contract, and policy parameters in terms that providers/members can understand

  • Explains services in terms of benefits so that providers/members understand their options

BACKGROUND/EXPERIENCE

RN with current unrestricted license required

Managed Care experience OR hospital utilization or case management experience is required.

3-5 years of clinical experience required (must include recent strong med/surg, overall in patient knowledge)

Medicaid experience is highly preferred!

Prior Authorization experience is preferred!

If currently an internal employee, knowledge of QNEXT is a huge plus!

Microsoft Windows experience (being able to use multiple windows and screens to work)

Microsoft Outlook and strong basic knowledge of Word is needed

Strong ability to type is necessary!

EDUCATION

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 (RN)

FUNCTIONAL EXPERIENCES

Functional - Medical Management/Medical Management - Clinical claim review/1-3 Years

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

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

Functional - Medical Management/Medical Management - Case Management/1-3 Years

Functional - Medical Management//

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User

Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

General Business/Applying Reasoned Judgment/ADVANCED

DESIRED SKILLS

Leadership/Collaborating for Results/ADVANCED

Service/Providing Solutions to Constituent Needs/ADVANCED

Benefits Management/Maximizing Healthcare Quality/FOUNDATION

ADDITIONAL JOB INFORMATION

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.

Job Function: Health Care