Aetna Quality Manager (RN) Nurse Consultant (MO) in Columbia, Missouri
Req ID: 52573BR
Responsible for the review and evaluation of clinical information and documentation.
Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and URAC requirements for workers comp.
Fundamental Components but not limited to the following:
-Performs utilization review activities including pre-certification, concurrent, and retrospective reviews
according to guidelines.
-Determines medical necessity of each request by applying appropriate medical criteria to first level
reviews and utilizing state or state recommended guidelines (if available).
-Assists with the negotiation of the appropriate length of care or alternative level of care when allowed by
-Refers case to a review physician when the treatment request does not meet necessity per guidelines,
when guidelines are not available, or per customer account instructions. Referrals must be made in a
timely manner, allowing the review physician time to make appropriate contact with the requesting
provider in accordance with departmental policy and within state or URAC mandated turn around times.
-Reviews, documents, and communicates all utilization review activities and outcomes including, but not
limited to, all calls made and received in regard to case communication and all demographic and service
group information. Sends appropriate system-generated letters to provider, claim payer, claimant, and
-Coordinates the appeal process as applicable with requesting and utilization review physician.
-May provide guidance and coaching to other utilization review nurses and participate in the orientation of
newly hired utilization nurses.
-Performs other duties as assigned.
-Active Registered Nurse license required.
-Minimum of 3 years RN clinical practice experience required.
-Previous managed care, workers compensation and/or utilization review experience preferred.
-Strong problem solving and analytical skills.
-Excellent communication, organizational, and interpersonal skills.
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is required
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Case Management/1-3 Years
Full-Time Telework (WAH)
Considered only for locations in a specific region, state, or city; training period in the office may be required (MO)
ADDITIONAL JOB INFORMATION
-Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
-Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
-Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
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.
Job Function: Health Care