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Aetna Utilization Management Clinical Consultant in Phoenix, Arizona

Req ID: 65276BR

Job Description

This role is office based in Phoenix, AZ with the potential to work at home following successful training.

Utilizes critical thinking and knowledge of program requirements, network and community resources, and Medicaid/Medicare benefits to facilitate appropriate physical and behavioral healthcare and social services for members. 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.

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 included but are not limited to:

-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

Qualifications Requirements and Preferences:

  • An RN license is required

  • 3+ years of clinical practice experience required

  • Behavioral/Mental Health experience strongly preferred

  • Managed care/utilization review experience preferred

Licenses/Certifications:

Nursing - Registered Nurse

Functional Skills:

Nursing - Clinical coverage and policies, Nursing - Concurrent Review/discharge planning, Nursing - Medical-Surgical Care

Technology Experience:

Aetna Application - Milliman, Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Required Skills:

Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts, Service - Working Across Boundaries

Desired Skills:

Benefits Management - Maximizing Healthcare Quality, General Business - Communicating for Impact, Technology - Leveraging Technology

Additional Job Information:

Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. This position also 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 with productivity and quality expectations. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

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.

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