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Utilization Management Clinical Consultant - Louisville, KY #7082435

Company: Aetna

Date: 12/03/2019

Category: Chemicals / Petro-Chemicals

City: Louisville, KY

Req ID: 65566BR


Job Description


Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.


Schedule is standard business hours and a weekend rotation on a quarterly basis.


This is a remote, telework role once fully trained after 6 months and production standards are met in the Lousiville, KY Aetna office.


Fundamental Components included but are not limited to:


Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care() Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)() Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment() Identifies members who may benefit from care management programs and facilitates referral() Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization(*)


Qualifications Requirements and Preferences:


Managed care/utilization review (prior authorization, retro review, or concurrent review) experience preferred


3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.


Behavioral health experience is preferred.


LICENSE REQUIRED


Registered Nurse (RN) with unrestricted active Kentucky state license.


Licenses/Certifications:


Nursing - Registered Nurse


Required Skills:


General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, Service - Working Across Boundaries


Desired Skills:


General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Consulting for Solutions


Additional Job Information:


Typical office working environment with productivity and quality expectationsWork 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 environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboarding


Benefit Eligibility


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


Job Function: Healthcare


Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.


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