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Utilization Management Clinical Consultant

Primary Location: Richmond, VA
Additional Locations: VA-Richmond
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Description:
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.

Onsite position.

Schedule is Monday-Friday standard business hours with a rotational on call 1-2 times per year for a weekend.

Fundamental Components:
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers 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:
Managed care/utilization review experience preferred
3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

LICENSE
Licensed independent Behavioral Health clinician (LCSW, LPC) in state of service or a Registered Nurse (RN) with unrestricted state license.

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 keyboarding

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts, General Business - Maximizing Work Practices

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, General Business - Communicating for Impact, General Business - Demonstrating Business and Industry Acumen

Functional Skills:
Clinical / Medical - Concurrent review / discharge planning

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel, Desktop Tool - Video Conferencing

Education:
Mental Health - Licensed Clinical Social Worker, Mental Health - Licensed Professional Counselor, Nursing - Registered Nurse

Potential Telework Position:
No

Percent of Travel Required:
N/A

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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