Aetna Appeals Nurse Consultant in Hartford, Connecticut
Req ID: 66685BR
This role is work at home. Hours are Monday-Friday 8-5 but weekends and holidays will be required on a rotating basis.
Responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.
Fundamental Components included but are not limited to:
-Reviews complaint/appeal requests of all clinical and benefit documentation.
-Considers all previous information as well as any additional records/data presented to render a recommendation/review.
-Data gathering requires navigation through multiple system applications.
-Contacts the provider of record, vendors or internal Aetna departments to obtain additional information.
-Accurately applies review requirements to assure case is reviewed by a practioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR).
-Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements and ERO eligibility which are required to support the appeals review.
-Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements.
-Condenses complex information into a clear and precise clinical picture while working independently.
-Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs.
-Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated.
Qualifications Requirements and Preferences:
-RN with current unrestricted state licensure required
-3+ years of clinical experience required
-Managed Care experience preferred
-Coding experience is preferred
Nursing - Registered Nurse
Nursing - Clinical claim review and coding, Nursing - Concurrent Review/discharge planning, Nursing - Medical-Surgical Care
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word
General Business - Communicating for Impact, General Business - Consulting for Solutions, Leadership - Creating Accountability
Additional Job Information:
Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. 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 Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.
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.