Aetna UM Nurse Consultant in Medford, Massachusetts
Req ID: 43679BR
Telework is considered only for locations in NY, NJ, CT, MA, RI, ME, and NH. Training period in the office may be required in Hartford, CT (1-2 days is office/3 days remote). Weekends are on a volunteer & rotational basis at this time.
The Utilization Management Nurse Consultant utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program assigned to the hospital markets. Requires an RN with unrestricted active license.
Fundamental Components include, but not are not limited to:
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.
-1-3 years Managed Care experience preferred
-3-5 years of clinical experience, (ex: ICU, Med/Surge, skilled nursing, long term care, post acute required)
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS:
Nursing/Registered Nurse (RN) is desired
Functional - Nursing/Clinical claim review and coding/1-3 Years
Functional - Nursing/Medical-Surgical Care/1-3 Years
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Legal and benefit interpretation/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
Considered only for locations in a specific region, state, or city; training period in the office may be required
posting under CT but may recruit from any NY, NJ, MA, RI, ME, and NH markets.
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 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