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.
What makes a successful nurse? Here are the traits we are looking for:
- Problem Solver
- Results Driven
- Technology Savvy
- Detail Oriented
- Good Listener
- Open Minded
- Team Player
Paid Time Off & Disability
MLTC Review Nurse (RN)Primary Location: New York, New York
Additional Locations: NY-New York Apply
This position works to review Pre-Enrollment assessments to make appropriate clinical determinations. Works closely with our Intake department, Assessment RNs, and our CMO, in making service approvals on which consumers base their enrollment decisions. Also involved in onboarding new members prior to their enrollment date, with initial outreach calls, explanation of benefits, and assistance in finding providers. Act as temporary CM until assigned to permanent CM once all the onboarding tasks have been completed.
This role Involves a high level of telephone communication to potential members and families, Assessment RNs, assessment RN vendors, and Aetna internal staff including the Intake department, CMO, CMs and CMAs.
69201Fundamental Components: Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
Review of assessment documentation and UAS to determine appropriate Service plan approvals for potential members. Background Experience: 3+ of years clinical practice experience required
RN with current unrestricted state licensure required
Excellent communication skills required
Case Management in an integrated model preferred
MLTC and UAS experience preferred.
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 keyboardingEffective communication skills, both verbal and written. Required Skills: Benefits Management - Understanding Clinical Impacts, General Business - Maximizing Work Practices, Service - Handling Service Challenges Desired Skills: Benefits Management - Interacting with Medical Professionals, Sales - Knowing Customers, Sales - Negotiating Collaboratively Functional Skills: Nursing - Case Management, Nursing - Clinical coverage and policies, Nursing - Concurrent Review/discharge planning, Nursing - Disease management, Nursing - Quality Management Technology Experience: 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. 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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