Appeals Nurse ConsultantPrimary Location: San Diego, California
Additional Locations: CA-San Diego, FL-Bradenton, MO-Columbia, ND-Bismarck, NY-Albany, TX-Cleburne, WV- Flatwoods Apply
This is an opportunity to join a great team that works well together and learn different types of appeals. This is a dynamic fast paced team which reviews clinical appeal issues across different clinical skill competencies (i.e. Med/Surg, Critical Care, Rehab, Skilled Nursing, Outpatient Services, Medications, Women's Health, etc.).
Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.
If you are a current work at home Aetna employee, you can stay work at home. If you are currently in an office you will need to stay in the office for a period of time, then after evaluated performance can be considered for from home.
Must live within 45 minutes of an Aetna office.
61614Fundamental Components: Reviews complaint/appeal requests of all clinical and benefit documentation. Considers all previous information as well as any additional records/data presented to render a recommendation/review. Data gathering requires navigation through multiple system applications. Contacts the provider of record, vendors or internal Aetna departments to obtain additional information. Accurately applies review requirements to assure case is reviewed by a practioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR).
Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements and ERO eligibility which are required to support the appeals review. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Condenses complex information into a clear and precise clinical picture while working independently.
Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs. Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated. Background Experience:
3+ years of clinical experience; Required
Unrestricted RN Licensure; Required
Hospital experience (Acute care); Preferred
Managed Care experience; Preferred
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.