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At Aetna, we’re pioneering a total approach to health and wellness, focusing on the whole person - body, mind, and spirit. Our more than 4,000 nurses are central to turning our member’s health ambitions, big and small, into achievements. Your role will include helping members stay well, manage health conditions, and access the right care at the right time. As you do this, we’ll support you in achieving more in your life and your work.

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Success Profile

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  • Collaborative
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Job Details

Registered Nurse (RN) Manager Utilization Management - 57846BR

Primary Location: San Diego, California
Additional Locations: CA-San Diego
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POSITION SUMMARY
Aetna Better Health is currently seeking a Manager of Utilization Management to join our California Medicaid team in our San Diego office. The Manager of Utilization Management develops, implements, supports and promotes clinical strategies, policies and programs that drive the delivery of quality healthcare to our members. The Manager is also responsible for the day-to-day oversight and management of clinical team processes including the organization and development of high performing teams. This is an in-office position.

Fundamental Components:
- Creates direction and communicates a business case for change by focusing on and addressing key priorities to achieve business results, while identifying opportunities to implement best practice approaches and introduce innovations to better improve outcomes, including evaluating and interpreting data, and meeting the financial, operational and quality objectives of the unit.
- Day-to-day management of concurrent review and prior authorizations teams for appropriate implementation and adherence with established practices, policies, and procedures.
- Develops, initiates, monitors, and communicates performance expectations; assesses developmental needs and collaborates with others to identify and implement action plans that support the development of teams.
- Works closely with functional area managers to ensure consistency in clinical interventions supporting our plan sponsors, and participates in the recruitment and hiring process for staff using clearly defined requirements.
- Acts as a single point of contact for the customer and the Account Team, including participation in customer meetings, implementation and oversight of customer cultural requirements, and support implementation of new customers.
- Consistently demonstrates the ability to serve as a model change agent and lead change efforts.
- Maintains compliance with policies and procedures and implements them at the employee level.
- Dedicated advocate for plan and members
Qualification Requirements:
- 5+ years in clinical area of expertise is required.
- 3+ years utilization management experience is required.
- 1+ years leadership or supervisory experience is required.
- Managed Care experience is required.
- Computer literacy and advanced proficiency with Microsoft Excel, Word, and web-based applications and databases is required.
- Ability to evaluate and interpret data, identify areas of improvement, and focus on interventions to improve outcomes is required.
- Ability to understand and create reports with productivity and service metrics, and identify gaps is required.
- Demonstrated ability to deliver presentations to both internal and external customers is required.
- Strong communication and organizational skills with an attention to detail are required.
Preferred Skills:
- MediCal experience is strongly preferred.
- Experience working in a regulatory environment is preferred.
- Some experience with concurrent review and prior authorizations is preferred
- Knowledge of community resources and provider networks is preferred.
- Familiarity with local health care delivery systems is preferred.
- Experience working with diverse teams and populations is preferred.
- Policy and procedure experience with a demonstrated ability to operationalize policies to desktops is preferred.

Education:
The minimum level of education required for candidates in this position is a Bachelor's degree or equivalent experience.

Licenses:
Active and unrestricted California Registered Nurse (RN) licensure isrequired.


FUNCTIONAL EXPERIENCES
Functional - Medical Management/Medical Management - Concurrent Review/4-6 Years
Functional - Clinical / Medical/Management: < 25 employees/1-3 Years
Functional - Medical Management/Medical Management - Managed Care/Insurance Administration/4-6 Years


TECHNOLOGY EXPERIENCES
Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User
Technical - Desktop Tools/Microsoft Word/4-6 Years/End User
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User


ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates'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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