Appeals Nurse ConsultantPrimary Location: Hartford, CT
Additional Locations: CT-Hartford Apply
64869Fundamental Components: 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.
Background Experience: 3+ years of clinical experience; Required
Managed Care experience; Preferred
Appeals or Utilization Management experience; Preferred
RN with current unrestricted state licensure; Required Additional Job Information: Must reside within 45 minutes of an Aetna office. 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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