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Appeals Nurse Consultant

Primary Location: San Diego, California
Additional Locations: CA-San Diego
Full time telework opportunity for candidates located in California.

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.

live within 45 minutes of an Aetna office.

Fundamental 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
  • Managed Care experience preferred
  • Hospital experience (Acute care); Preferred
  • Knowledge of California HMO plans; Preferred
  • RN with current unrestricted state licensure required

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:
Leadership - Collaborating for Results

Desired Skills:
Leadership - Anticipating and Innovating

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

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Nursing - Registered Nurse (RN)

Potential Telework Position:

Percent of Travel Required:

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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