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Appeals Nurse Consultant

Primary Location: Hartford, CT
Additional Locations: CT-Hartford, MI-Detroit, NC-High Point, OH-Canton, PA-Allentown, TX-Arlington, VA-Richmond
This full time position is part of a team of a number of Complaint and Appeal Nurse Analysts and Complaint and Appeal Analysts. Our team provides comprehensive post-service utilization management review for providers. Part of our team also reviews cases that are DRG PrePay contracts. All of our Complaint and Appeal Nurse Analysts are provided on the job training, and work collaboratively with a preceptor.
Responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.

Schedule is Monday-Friday only. No nights, no weekends and no holidays!

Remote role.

Fundamental Components:
Reviews complaint/appeal requests of all clinical and benefit documentation. Considers all previous information as well as any additional records/data presented to render a recommendation/review. Data gathering requires navigation through multiple system applications. Contacts the provider of record, vendors or internal Aetna departments to obtain additional information. Accurately applies review requirements to assure case is reviewed by a practioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements and ERO eligibility which are required to support the appeals review. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Condenses complex information into a clear and precise clinical picture while working independently. Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs. Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated.
Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins. Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins. Exposure to a wide variety of clinical appeal issues. • Review post service Legacy Aetna and Legacy Coventry provider appeal requests. • Collaborate with Aetna medical directors. • Become a subject matter expert with regard to the Centers for Medicare & Medicare Services Guidelines, Industry medical necessity guidelines of MCG and/or InterQual. • Contribute to Aetna’s strong Medicare star quality ratings.

Background Experience:
3 years of clinical experience required
Managed Care experience preferred
Complaint & appeals experience is highly preferred
Coding ICD 10 and CPT codes experience is preferred
Medicare experience is preferred
Chart and records review experience is needed.

RN with active/current unrestricted state licensure required.

Additional Job Information:
Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. 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 Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.

Desired Skills:
General Business - Communicating for Impact, Leadership - Collaborating for Results, Leadership - Creating Accountability

Functional Skills:
Nursing - Clinical claim review and coding, Nursing - Critical Care, Nursing - Emergency Room, Nursing - Medical-Surgical Care

Nursing - Registered Nurse

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position.

Candidate Privacy Information:
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.


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