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.
What makes a successful nurse? Here are the traits we are looking for:
- Problem Solver
- Results Driven
- Technology Savvy
- Detail Oriented
- Good Listener
- Open Minded
- Team Player
Paid Time Off & Disability
Prior Authorization Registered Nurse (RN) - WV MCDPrimary Location: Charleston, West Virginia
Additional Locations: WV-Charleston Apply
The Prior Authorization Nurse utilizes critical thinking and knowledge of program requirements, network and community resources, and benefits to facilitate appropriate physical and behavioral healthcare for members.
64899Fundamental Components: - Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
- Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit administration.
- 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.
- Identifies members for referral opportunities to integrate with other products, services and/or programs.
- Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations. Background Experience: • 3+ years clinical practice experience (e.g., hospital setting, LTSS, alternative care setting such as home health or ambulatory care) is required.
• 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.
• Ability to work and provide coverage on weekends on a rotational basis is required.
• Self-motivated and confident making clinical decisions with ability to influence and shape clinical outcomes is required.
• Strong organizational skills with an attention to detail is required.
• Experience and knowledge in clinical guidelines, systems/tools (i.e., MCG, Interqual, LOCUS, CASII, ASAM) is preferred.
• Managed Care experience is preferred.
• Utilization Review experience is preferred.
• Knowledge of provider networks and delivery, and ability to interface with providers is preferred.
• Behavioral Health and physical health integrated care experience is a plus.
Additional Job Information: Required Skills: Benefits Management - Interacting with Medical Professionals, Finance - Managing Aetnas Risk, General Business - Applying Reasoned Judgment Desired Skills: General Business - Communicating for Impact, General Business - Consulting for Solutions, General Business - Demonstrating Business and Industry Acumen Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel 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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