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Aetna is now a CVS Health Company

Utilization Management Nurse Consultant

Primary Location: San Antonio, TX
Additional Locations: TX-San Antonio
Office-based position in San Antonio, TX.

Positions include Precertification, Concurrent Review, and Retro Review. Must be Texas Based as required by the Plan. This position requires an RN with an unrestricted active license. The Utilization Manager gathers clinical information, applies appropriate clinical criteria/guidelines, policies, procedures, uses clinical judgment to render coverage determinations/recommendations along the continuum of care and communicates with providers and other parties to facilitate care/treatment. You will identify members for referral opportunities to integrate with other products, services and/or programs and opportunities in order to promote quality effectiveness of Healthcare Services and effective benefit utilization. In addition, as a UM Nurse Consultant you will utilize your clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program including but not limited to; precertification, pre determination, concurrent review, retro review, and discharge planning activities of the TRS members. This is a telephonic position which involves sitting for extended periods, talking on the telephone and typing on the computer. Typical business working environment with productivity and quality expectations.

Fundamental Components:
UM Nurse Consultants require: - Effective communication skills, both verbal and written, and the ability to effectively and credibly discuss routine and complex care situations with both external and internal clinicians. - Intellectual humility, empathy, integrity, courage, and confidence to drive fair and purposeful and appropriate decisions. - The ability to prioritize and effectively adapt to a fast paced changing environment. - Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.

Background Experience:
RN licensure required
5+ years clinical experience required

Utilization management experience preferred
Managed care experience preferred

Additional Job Information:
This is a fast paced unit with participants who often have complex nursing needs. Our UMNCs must be able to work efficiently with providers, participants, and families to determine gaps in medical care and be able to assist in comprehensive discharge planning. This is a team dedicated to the plan sponsor TRS, as part of the Arlington and San Antonio Customer Care Unit.

Required Skills:
Benefits Management - Interacting with Medical Professionals, General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, Leadership - Driving a Culture of Compliance, Service - Providing Solutions to Constituent Needs

Functional Skills:
Medical Management - Medical Management - Managed Care/Insurance Administration, Nursing - Case Management, Nursing - Concurrent Review/discharge planning, Nursing - Discharge Planning

Technology Experience:
Computer Operation - System and Console Operations, Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Nursing - Registered Nurse

Potential Telework Position:

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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