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Precertification Nurse

Primary Location: Houston, Texas
Additional Locations: TX-Houston
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Description:

Office-based position in Houston, TX.

TheUtilization Management Nurse Consultant utilizes clinical skills to support thecoordination, documentation and communication of medical services and/orbenefit administration determinations working in a very fast paced environment.



Fundamental Components:

Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services. Coordinates and communicates with providers, members and other
parties to facilitate optimal care and treatment often collaborating with Aetna medical directors and other internal departments. Identifies members who may benefit from care management programs and facilitates referrals as well as
identify opportunities to promote quality effectiveness of healthcare services and benefit utilization. Utilizes technical skills to multitask through multiple systems at a rapid pace in order to process Precert requests timely and accurately. Proficient in both verbal and written communication in order to request information, review clinical material, make appropriate decisions based on medical necessity and/or benefits and communicate those decisions to
both providers and members.



Background Experience:

RN licensure is required

3+ years clinical experience is required


Utilization review or pre-cert experience is preferred

Managed care experience is preferred



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:
Service - Working Across Boundaries, Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality

Desired Skills:
Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts, Leadership - Collaborating for Results

Functional Skills:
Nursing - Clinical coverage and policies, Nursing - Concurrent Review/discharge planning, Nursing - Home Health Care Ambulatory Nursing, Nursing - Medical-Surgical Care

Technology Experience:
Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - TE Microsoft Excel

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. 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

Click To Review Our Benefits (PDF)

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