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.
3+ years of clinical experience and concurrent unrestricted State licensure (RN) is required
Must be computer literate to navigate through internal and external computer systems.
Outstanding interpersonal & negotiation skills to effectively establish positive relationships with all constituents both internal and externally.
Must be able to exercise independent and sound judgment in clinical decision making.
Strong verbal & written communication skills.
Organizational skills, effective time management and ability to manage multiple priorities are a must.
Managed care or utilization management experience preferred.
Registered Nurse (RN) is required
3+ years of clinical experience is required
3+ years Utilization Review experience is required
Managed Care experience is preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is required
Benefits Management/Interacting with Medical Professionals/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
Leadership/Collaborating for Results/ADVANCED
Considered for any US location; training period in the office may be required
ADDITIONAL JOB INFORMATION
Dynamic fast paced team which reviews clinical appeals issues across different clinical skill competencies
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.