Aetna UM Clinical Consultant in New Albany, Ohio

Req ID: 52213BR

Please note: This is an in office position in New Albany, OH

POSITION SUMMARY

The Concurrent Review 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.

Fundamental Components:

-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:

  • Registered Nurse (RN) with unrestricted state license is required

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

  • Must be comfortable working over the computer and working across multiple software applications and screens simultaneously

  • Proficiency with Microsoft Office Suite is required

    Managed care/utilization review experience strongly preferred.

    Knowledge/Experience with Medicaid highly desired.

    EDUCATION

  • The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.

  • BSN is preferred

    LICENSES AND CERTIFICATIONS

    Nursing/Registered Nurse (RN) is required

    FUNCTIONAL EXPERIENCES

    Functional - Medical Management/Medical Management - Discharge planning/3+ Years

    Functional - Medical Management/Medical Management - Concurrent Review/3+ Years

    Functional - Medical Management/Medical Management - Direct patient care/3+ Years

    Functional - Clinical / Medical/Concurrent review / discharge planning/3+ Years

    TECHNOLOGY EXPERIENCES

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

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

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

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

    ADDITIONAL JOB INFORMATION

    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.

    Aetna takes our candidates'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