Aetna Concurrent Review Consultant (RN) in Richmond, Virginia
Req ID: 54366BR
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.
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:
3-5 years clinical practice experience, e.g., hospital setting, LTSS, alternative care setting such as home health or ambulatory care required.
Registered Nurse (RN) with unrestricted VA state license
Managed care/ utilization review experience strongly preferred.
Experience with Concurrent Review
Strong documentation skills and broad based clinical knowledge
Behavioral health and physical health integrated care experience
Proficiency with MS Office Suite.
Experience and knowledge required in clinical guidelines, systems/tools i.e., Milliman, Interqual
Knowledge of provider networks and delivery, ability to interface with providers
Possesses sound clinical judgment
Strong organizational skills with an attention to detail
Ability to work independently and on a team
Ability to work with all levels of management
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Nursing/Registered Nurse is required
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Additional Job Information:
Positions may require working on a telephone queue or on-site visitation
Self-motivated and confident making clinical decisions, ability to influence and shape clinical outcomes
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
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
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
Typical office working environment with productivity and quality expectations.
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. 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.
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.
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
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.