UM Nurse Consultant

Aetna Inc. Buffalo , NY 14202

Posted 4 weeks ago

Job Description:

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.

Fundamental Components:

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.

Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.


RN licensure required
3+ years clinical experience required

UM experience preferred

Managed Care experience preferred


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


Nursing/Registered Nurse (RN) is required



  • Nursing/Concurrent Review/discharge planning/1+ Years


  • Medical Management/Medical Management

  • Hospital/1+ Years



  • Desktop Tools/Microsoft Word/1+ Years/End User


  • Desktop Tools/Microsoft Outlook/1+ Years/End User


  • Desktop Tools/TE Microsoft Excel/1+ Years/End User


Benefits Management/Interacting with Medical Professionals/ADVANCED

Benefits Management/Supporting Medical Practice/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION


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.

See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Safety Net Behavioral Health Childrens UM Coordinator 014467

Univera Healthcare

Posted 2 months ago

VIEW JOBS 10/16/2018 12:00:00 AM 2019-01-14T00:00 Two Positions Available The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve. Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce. OUR COMPANY CULTURE: Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits. Summary This position is responsible for coordinating, integrating and monitoring the use of behavioral health services in accordance with departmental, corporate, state, federal, accreditation standards, as well as CMS standards if appropriate to the case for the medically fragile children. The incumbent assists, supports, advocates, and educates the members, family, providers, and employer groups through a continuum of care for this special needs population. The position delivers efficient, effective and seamless care to members. Essential Responsibilities/Accountabilities * Performs clinical review of the appropriateness and quality of behavioral health services, applying guidelines and medical policies. * Performs a clinical assessment and coordinates care on all members discharged from a behavioral health inpatient level of care and assists members in accessing the most appropriate next level of care. * Carries out job responsibilities in accordance with departmental, corporate, state, federal and accreditation standards. * Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical knowledge, members' specific health plan benefits, and efficient care delivery processes. Ensures compliance with policy and procedure. Identifies and refers potential quality of care and utilization issues to Health Plan medical director. * Utilizes appropriate communication techniques with members and providers to obtain behavioral health information, assesses need for continuation of services, assists members in obtaining needed services, as appropriate, interacts with the treating physician or other providers of care. * Works in collaboration with members' physicians and other health care providers to assess the needs of the member, facilitate development of an interdisciplinary plan of care, coordinates services, evaluates effectiveness of services and modifies the member plan of care as necessary. * Acts as a resource to the provider community, explaining processes for accessing Health Plan to perform clinical review identifying appropriate community resources, or otherwise interacts with Health Plan programs and services. * Provides appropriate resources and assistance to members with regards to managing their health care across the continuum of care * Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. As necessary, will provide assistance to Claims and/or Customer Service Departments with the definition of medical terms, including diagnosis and procedures, as related to benefit or coverage issues. * Measurement of job performance includes meeting established corporate and department standards in terms of volume and accuracy as measured by audit. * Interacts with members, providers, families and internal customers in scheduling patient treatments or other procedures. * Evaluates the effectiveness of treatment(s) and accuracy of diagnosis. Modifies plan and diagnosis, as necessary. * Maintains current and accurate records for statistics, cost effectiveness, admissions and discharge plans * Offers process improvement suggestions and participates in the solutions of more complex issues/activities. * Mentors junior staff & assists with coaching whenever necessary. * Provides consistent positive results of audits. * Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health. * Manages more complex assignments; larger caseloads and a greater number of facilities. * Displays leadership and serves as a positive role model to others in the department. * Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs. * Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. * Regular and reliable attendance is expected and required. * Performs other functions as assigned by management. Minimum Qualifications * RN with current New York State license (BSN Preferred) or NYS Licensed Clinical Behavioral Health Professional – LMFT, LCSW, LMHC. * Minimum of three years of experience in managed care treating children in a BH setting. * Knowledge and experience in Children's health and BH services, HCBS, EBPs, EPSDT services and social service programs preferred. * Strong communication skills; written, writing and listening. * Must demonstrate proficient experience in use of a computer. Example-creating documents, Excel, Internet and/or email. * Experience in interpreting health plan benefit plans preferred. * Knowledge of Intermural criteria and/or Medicare guidelines preferred. * Shows an understanding and works accordingly in order to meet the highest quality standards. * Must demonstrate work habits sufficient to be able to work independently on a daily basis. * Strong organizational skills required. * Ability to independently travel throughout the Health Plan markets. Physical Requirements Ability to travel, ability to work long hours on a computer In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Univera Healthcare Buffalo NY

UM Nurse Consultant

Aetna Inc.