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Utilization Management Nurse Consultant

Primary Location: San Antonio, TX
Additional Locations: TX-San Antonio
This is an in office- position in the San Antonio, TX office.

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.

As a Utilization Management Nurse, you will help support the USAA In Touch Care Premier Dedicated team to provide comprehensive coordination of medical services for the membership.
This is an in-office Utilization Management position in the San Antonio office,using a computer station and may require sitting for extended periods of time. Candidates must possess good computer skills. This position is ideal for a Registered Nurse seeking a fast paced environment. The UM Nurse Consultant is an integral member of the care management team utilizing clinical skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options and services thereby aiding in facilitating appropriate inpatient healthcare management and effective discharge planning to improve the outcomes for members. More specifically, the inpatient care process includes: obtaining necessary information from providers and facilities; assessment of a member's clinical condition and ongoing medical services and treatments to determine medical appropriateness; guide the setting for medical intervention to achieve optimum length of stay for members. Authorize and coordinate the required services, in accordance with the benefit plan. The UM Nurse Consultant determines appropriate levels of coverage for inpatient stay using clinical judgment and application of Milliman Care Guidelines to meet the member's needs. The UM Nurse Consultant periodically evaluates the member's progress in meeting the inpatient care plan / discharge goals and revises and coordinates the plan with the hospital discharge planner, the attending physician, and the patient/family when appropriate. The UMNC assists in developing an approach to removing barriers and collaborates with UR departments to facilitate adherence to the care plan.

Fundamental Components:
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

Background Experience:
RN licensure in TX required
3+ years clinical experience required

Utilization management experience preferred
Managed care experience preferred
Candidate must possess strong customer service skills including: attention to customers & sensitivity to certain issues.

Additional Job Information:
Typical office working environment with productivity and quality expectations Work 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 environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Technology - Leveraging Technology

Desired Skills:
Leadership - Collaborating for Results, Service - Providing Solutions to Constituent Needs

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

Technology Experience:
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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