Appeals Nurse Consultant

Aetna Inc. Kansas City , MO 64126

Posted 2 weeks ago

Job Description:

POSITION SUMMARY

This full time position is part of a team of a number of Complaint and Appeal Nurse Analysts and Complaint and Appeal Analysts. Our team provides comprehensive post-service utilization management review for providers.

Part of our team also reviews cases that are DRG assignment contracts. All of our Complaint and Appeal Nurse Analysts are provided on the job training, and work collaboratively with a preceptor.

Fundamental Components:

Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins.

Exposure to a wide variety of clinical appeal issues. Review post service Legacy Aetna and Legacy Coventry provider appeal requests.

Collaborate with Aetna medical directors. Become a subject matter expert with regard to the Centers for Medicare & Medicare Services Guidelines, Industry medical necessity guidelines of MCG and/or InterQual. Contribute to Aetnas strong Medicare star quality ratings.

BACKGROUND/EXPERIENCE:

  • Managed Care experience preferred

  • 3-5 years of clinical experience required

  • Appeals/Utilization Management experience; Preferred

EDUCATION

The minimum level of education required for candidates in this position is an Associate's degree.

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse in the State of Residence is required

FUNCTIONAL EXPERIENCES

Functional

  • Nursing/Critical Care/1-3 Years

Functional

  • Nursing/Concurrent Review/discharge planning/1-3 Years

Functional

  • Nursing/Medical-Surgical Care/1-3 Years

Functional

  • Nursing/Emergency Room/1-3 Years

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Leadership/Collaborating for Results/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

ADDITIONAL JOB INFORMATION

Must live within 45 minutes of an Aetna office if current teleworker.

If currently working in an Aetna office, will remain working in the office.

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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Appeals Nurse Consultant

Aetna Inc.