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Aetna is now a CVS Health Company

Appeals Nurse Consultant

Primary Location: Hartford, CT
Additional Locations: CT-Hartford
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Description:
This full time position is part of a team of a number of Complaint and Appeal Nurse Analysts and Complaint and Appeal Analysts. Our team provides comprehensive post-service utilization management review for providers. Part of our team also reviews cases that are DRG PrePay contracts. All of our Complaint and Appeal Nurse Analysts are provided on the job training, and work collaboratively with a preceptor.

Schedule is regular business hours Monday-Friday.

Fundamental 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:
Managed Care experience preferred
3 years of clinical experience required
Coding experience highly preferred


EDUCATION
ASN or equivalent education

LICENSE
RN required active and no restrictions



Additional Job Information:
Ability to navigate through multiple computer systems, on our production based team.

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.

Click To Review Our Benefits (PDF)

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