At Aetna, 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
Utilization Management Clinical Consultant (RN)Primary Location: Phoenix, Arizona
Additional Locations: AZ-Phoenix Apply
This role is office based in Phoenix, AZ with the potential to work at home following successful training.
Utilizes critical thinking and knowledge of program requirements, network and community resources, and Medicaid/Medicare benefits to facilitate appropriate physical and behavioral healthcare and social services for members. 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.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
- Gathers 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
- An RN license is required
- 3+ years of clinical practice experience required
- Behavioral/Mental Health experience strongly preferred
- Managed care/utilization review experience preferred
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
Sedentary work involving periods of sitting, talking and listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as the PC monitor.
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