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Nurse Careers

At Aetna, we’re pioneering a total approach to health and wellness, focusing on the whole person - body, mind, and spirit. Our more than 4,000 nurses are central to turning our member’s health ambitions, big and small, into achievements. Your role will include helping members stay well, manage health conditions, and access the right care at the right time. As you do this, we’ll support you in achieving more in your life and your work.

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Success Profile

What makes a successful nurse? Here are the traits we are looking for:

  • Collaborative
  • Deadline-oriented
  • Organized
  • Problem Solver
  • Results Driven
  • Technology Savvy
  • Adaptable
  • Compassionate
  • Detail Oriented
  • Flexible
  • Good Listener
  • Open Minded
  • Responsible
  • Team Player

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Benefits

  • Health

  • Wellness

  • Financial

  • Paid Time Off & Disability

  • Life Insurance

  • Additional Benefits

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Job Details

Concurrent Review Clinician (RN) - WV MCD

Primary Location: Charleston, West Virginia
Additional Locations: WV-Charleston
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Description:
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.

The UM Clinical Consultant utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services.

Fundamental Components:
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support).
Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment.
Identifies members who may benefit from care management programs and facilitates referral.
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.


Background Experience:
3+ years' clinical practice experience (e.g., hospital setting, LTSS, alternative care setting such as home health or ambulatory care) is required.
Registered Nurse (RN) with active and unencumbered WV State license (BSN preferred) is required.
Proficiency with computer skills, which includes the Microsoft Office suite, navigating multiple systems and keyboarding is required.
Strong documentation skills and broad-based clinical knowledge is required.
Self-motivated and confident making clinical decisions; ability to influence and shape clinical outcomes is required.
Strong organizational skills with an attention to detail is required.
Ability to work and provide coverage on weekends and holidays, as assigned and on a rotational basis, is required.
Experience and knowledge in clinical guidelines, systems/tools (i.e., Milliman, Interqual, LCDs/MCSs, LOCUS, CASII, ASAM) is strongly preferred.
Managed care/utilization review experience is strongly preferred.
Knowledge of provider networks and delivery, and ability to interface with providers is strongly preferred.
Behavioral Health and physical health integrated care experience is preferred.


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

Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West 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 our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.

Required Skills:
Finance - Managing Aetnas Risk, General Business - Applying Reasoned Judgment, Technology - Leveraging Technology

Desired Skills:
General Business - Consulting for Solutions, Leadership - Collaborating for Results, Leadership - Fostering a Global Perspective

Functional Skills:
Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Direct patient care (hospital, private practice), Medical Management - Medical Management - Clinical claim review

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Education:
Mental Health - Licensed Clinical Social Worker, Nursing - Registered Nurse (RN)

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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