Utilization Management Prior Authorization NursePrimary Location: Downers Grove, IL
Additional Locations: IL-Downers Grove Apply
65210Fundamental Components: Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers 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: Managed Care; Preferred
Utilization review 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 expectationsWork 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 environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboarding Required Skills: General Business - Applying Reasoned Judgment, General Business - Consulting for Solutions, General Business - Demonstrating Business and Industry Acumen Desired Skills: General Business - Maximizing Work Practices, Leadership - Collaborating for Results Functional Skills: Clinical / Medical - Direct patient care (hospital, private practice), Clinical / Medical - Precertification Technology Experience: Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook 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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