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Nurse Careers

At Aetna, a CVS Health Company, 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

Medical Review Nurse (RN)

Primary Location: Dallas, Texas
Additional Locations: TX-Dallas
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Description:
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes critical thinking and knowledge of program requirements, network and community resources, and Medicaid benefits to facilitate appropriate physical and behavioral healthcare and social services for members. 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:
Manage Care / Utilization Review Experience; preferred
NICU, Pediatric, Labor and Delivery Experience; preferred
3+ years Clinical Practice Experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care; required.
Registered Nurse (RN) with unrestricted state license; 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.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment

Desired Skills:
Benefits Management - Interacting with Medical Professionals, General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results

Functional Skills:
Nursing - Concurrent Review/discharge planning, Nursing - Discharge Planning, Nursing - Emergency Room, Nursing - Maternal and Infant care, Nursing - Medical-Surgical Care, Nursing - Mental Health

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Education:
Nursing - Registered Nurse (RN)

Potential Telework Position:
No

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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