Aetna Concurrent Review Nurse (Virginia Medicaid) - 51143BR in Bristol, Virginia

Req ID: 51143BR

Position Summary:

The Concurrent Review RN/Consultant utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.

Job Responsibilities:

-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

    Background/Experience Desired:

  • 3-5 years clinical practice experience, e.g., hospital setting, LTSS, alternative care setting such as home health or ambulatory care required.

  • Managed care/utilization review experience strongly preferred.

  • RN with unrestricted VA state license.

  • BSN is preferred.

  • Proficiency with MS Office Suite.


    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)

    Functional Experiences:

    Functional - Clinical / Medical/Concurrent review / discharge planning/4-6 Years

    Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years

    Functional - Medical Management/Medical Management - Concurrent Review/4-6 Years

    Technology Experiences:

    Technical - Desktop Tools/Microsoft Word/4-6 Years/End User

    Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User

    Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User

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

    Additional Job Information:

    Experience and knowledge required in clinical guidelines, systems/tools i.e., Milliman, Interqual, Knowledge of provider networks and delivery, ability to interface with providers. Possesses sound clinical judgment. Strong organizational skills with an attention to detail. Ability to work independently and on a team. Ability to work with all levels of management. Strong documentation skills and broad based clinical knowledge. Behavioral health and physical health integrated care experience.

    Position may require working on a telephone queue or on-site visitation. Self-motivated and confident making clinical decisions, ability to influence and shape clinical outcomes. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Sedentary work involving periods of sitting, talking, listening. 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. 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.

    Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of Virginia Medicaid members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Virginia, and we will support you all the way.

    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. 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.

    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.

    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