Aetna Registered Nurse (RN) - Utilization Management Nurse Consultant in Sunrise, Florida
Req ID: 37991BR
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.
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
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!
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 - 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//
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
Benefits Management/Interacting with Medical Professionals/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
General Business/Applying Reasoned Judgment/ADVANCED
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