Aetna UM Nurse Consultant in Sacramento, California
Req ID: 50864BR
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
BACKGROUND/EXPERIENCE:Managed Care experience; Preferred3-5+ years of clinical experience; RequiredEDUCATION
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
RN Registered Nurse California; Required
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Clinical claim review and coding/1-3 Years
Functional - Nursing/Medical-Surgical Care/1-3 Years
Benefits Management/Interacting with Medical Professionals/ADVANCED
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
General Business/Consulting for Solutions/FOUNDATION
General Business/Applying Reasoned Judgment/ADVANCED
General Business/Turning Data into Information/FOUNDATION
Service/Providing Solutions to Constituent Needs/ADVANCED
ADDITIONAL JOB INFORMATION
Post Acute Focus
Requires CA License
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.
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Job Function: Health Care