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.
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.
Minimum of 3-5 years of clinical experience required.
Advanced Computer skills: Outlook, Excel and Word required.
Active, unrestricted RN license required.
Managed Care experience preferred.
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
Licenses and Certifications:
Registered Nurse (RN) is required.
Internal candidates who are currently WAH will remain WAH. Candidates who are in the office will remain in the office with no potential for WAH. External candidates will WAH.
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.