Skip to main content

Utilization Management Clinical Consultant

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
Apply
Description:

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.

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:
  • An RN license is required
  • 3+ years of clinical practice experience required
  • Behavioral/Mental Health experience strongly preferred
  • Managed care/utilization review experience preferred


Additional Job Information:
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. This position also 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 with productivity and quality expectations. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts, Service - Working Across Boundaries

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, General Business - Communicating for Impact, Technology - Leveraging Technology

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

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

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)

Apply

Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.