Aetna VA MCD Prior Auth Nurse in Richmond, Virginia
Req ID: 51147BR
The Prior Authorization Nurse (LPN or LVN) position facilitates the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. LPN/LVN with current unrestricted VA state licensure required.
Promotes/supports quality effectiveness of Healthcare Services and Benefit Utilization
Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit administration
Collects information to support the process of rendering appropriate medical necessity/benefit determinations
Identifies members for referral opportunities to integrate with other products, services and/or programs
Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations.
Minimum of 3 years BH experience required;. 2+ years clinical experience required with LPN/LVN unrestricted active VA license.
Previous MCO experience strongly desired; computer literacy required to navigate through internal/external computer systems, including Microsoft Word and Excel.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.
The highest level of education desired for candidates in this position is an Associate's degree or equivalent experience.
Licenses and Certifications:
Nursing/Licensed Practical Nurse (LPN) is desired
Nursing/Licensed Vocational Nurse (LVN) is desired
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years
Functional - Clinical / Medical/Precertification/1-3 Years
Functional - Medical Management/Medical Management - Precertification/1-3 Years
Functional - Medical Management/Medical Management - Clinical coverage and policies/1-3 Years
Functional - Nursing/Mental Health/1-3 Years
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User
Service/Providing Solutions to Constituent Needs/FOUNDATION
General Business/Applying Reasoned Judgment/FOUNDATION
Leadership/Collaborating for Results/FOUNDATION
Leadership/Fostering a Global Perspective/FOUNDATION
Finance/Managing Aetna s Risk/FOUNDATION
Additional Job Information:
Experience and knowledge required in clinical guidelines, systems and tools i.e., MCG, InterQual, Broad-based medical and surgical background
Behavioral Health experience is strongly preferred Position may include working on a telephone queue Knowledge of community resources and provider networks
Familiarity with local health care delivery systems Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written.
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.
Typical office working environment with productivity and quality expectations.
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of Virginia Medicaid members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Virginia, and we will support you all the way.
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.
Aetna takes our candidate'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