Appeals Nurse ConsultantPrimary Location: San Diego, CA
Additional Locations: CA-San Diego, FL-Fort Myers, MO-Kansas City, NJ-Bridgeton, OH-Columbus, VA-Lynchburg Apply
This is an opportunity to join a great team that works well together and learn different types of appeals! The team is supportive and helpful! This is a dynamic fast paced team which reviews clinical appeal issues across different clinical skill competencies (i.e. Med/Surg, Critical Care, Outpatient Services, Medications, Women's Health, etc.).Responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records 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. Requires an RN with unrestricted active license.
66813Fundamental 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: RN licensure required
3+ years clinical experience required
Utilization management or pre-cert experience highly preferred
Managed care experience preferred 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, Leadership - Driving a Culture of Compliance, Technology - Leveraging Technology Desired Skills: Benefits Management - Maximizing Healthcare Quality, Benefits Management - Supporting Medical Practice, General Business - Communicating for Impact Functional Skills: Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Precertification, Nursing - Clinical coverage and policies, Nursing - Medical-Surgical Care Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word Education: Nursing - Registered Nurse Potential Telework Position: Yes 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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