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A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Utilization Management Clinical Consultant

Primary Location: Phoenix, Arizona
Additional Locations: AZ-Phoenix
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Description:
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.

Fundamental Components:
  • 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


Background Experience:
  • 3 or more years recent clinical practice experience, e.g., hospital setting, alternative care setting such as ambulatory care required
  • Behavioral/Mental Health experience preferred
  • Managed care/utilization review experience preferred
  • Registered Nurse (RN) with unrestricted state license required


Additional Job Information:

Typical office working environment with productivity and quality expectations


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.



Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, Service - Case Administration, Service - Handling Service Challenges

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

Technology Experience:
Aetna Application - Milliman, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Education:
Nursing - Registered Nurse, Nursing - Registered Nurse (RN)

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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