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Aetna Prior Authorization Registered Nurse (RN) - WV MCD in Charleston, West Virginia

Req ID: 64899BR

Job Description

This is a full time in office role in Charleston, WV. There is potential for telework after a certain period of employment.

The Prior Authorization Nurse utilizes critical thinking and knowledge of program requirements, network and community resources, and benefits to facilitate appropriate physical and behavioral healthcare for members.

Fundamental Components included but are not limited to:

  • Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization

  • Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit administration.

  • 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.

  • Identifies members for referral opportunities to integrate with other products, services and/or programs.

  • Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations.

Qualifications Requirements and Preferences:

• 3+ years clinical practice experience (e.g., hospital setting, LTSS, alternative care setting such as home health or ambulatory care) is required.

• RN with active and unencumbered WV State license (BSN preferred) is required.

• Proficiency with computer skills, which includes the Microsoft Office suite, navigating multiple systems and keyboarding is required.

• Strong documentation skills and broad-based clinical knowledge is required.

• Ability to work and provide coverage on weekends on a rotational basis is required.

• Self-motivated and confident making clinical decisions with ability to influence and shape clinical outcomes is required.

• Strong organizational skills with an attention to detail is required.

• Experience and knowledge in clinical guidelines, systems/tools (i.e., MCG, Interqual, LOCUS, CASII, ASAM) is preferred.

• Managed Care experience is preferred.

• Utilization Review experience is preferred.

• Knowledge of provider networks and delivery, and ability to interface with providers is preferred.

• Behavioral Health and physical health integrated care experience is a plus.


Nursing - Registered Nurse

Technology Experience:

Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Required Skills:

Benefits Management - Interacting with Medical Professionals, Finance - Managing Aetnas Risk, General Business - Applying Reasoned Judgment

Desired Skills:

General Business - Communicating for Impact, General Business - Consulting for Solutions, General Business - Demonstrating Business and Industry Acumen

Additional Job Information:

Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West 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 our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Job Function: Healthcare

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.