Appeals Nurse ConsultantPrimary Location: Bismarck, North Dakota
Additional Locations: CT-Hartford, FL-Orlando, IA-Urbandale, KY-Lexington, MN-Minneapolis, MO-Chesterfield, MS-Ridgeland, ND-Bismarck, TX-Austin Apply
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.
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.
3+ years of clinical experience required
RN with current unrestricted state licensure required.
Managed Care experience preferred
Appeals/Utilization Management experience preferredAdditional Job Information: If internal employee and already in the office, will
remain in the office. If internal employee and already teleworker, will remain
teleworker. Must live within 45 minutes from an Aetna office.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 - Applying Reasoned Judgment, General Business - Maximizing Work Practices, Technology - Leveraging Technology Functional Skills: Nursing - Clinical coverage and policies, Nursing - Concurrent Review/discharge planning, Nursing - Medical-Surgical Care Technology Experience: Hardware - PCs Education: Nursing - Registered Nurse Potential Telework Position: Yes Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this 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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