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Utilization Management Clinical Consultant (RN)

Company: Aetna
Location: San Diego
Posted on: January 16, 2019

Job Description:

Req ID: 56554BR This is an office based role in San Diego, CA. POSITION SUMMARY 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. Fundamental components include 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 function -Gathers 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 BACKGROUND/EXPERIENCE An RN license is required 3+ years clinical practice experience required 3+ years of concurrent review experience required Managed care/utilization review experience preferred EDUCATION The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience. LICENSES AND CERTIFICATIONS Nursing/Registered Nurse (RN) is required FUNCTIONAL EXPERIENCES Functional - Nursing/Concurrent Review/discharge planning/1-3 Years REQUIRED SKILLS Benefits Management/Interacting with Medical Professionals/ADVANCED Benefits Management/Maximizing Healthcare Quality/FOUNDATION Benefits Management/Supporting Medical Practice/ADVANCED Leadership/Collaborating for Results/ADVANCEDDESIRED SKILLS Benefits Management/Supporting Medical Practice/ADVANCED Leadership/Driving a Culture of Compliance/FOUNDATION Service/Providing Solutions to Constituent Needs/ADVANCED TECHNOLOGY EXPERIENCES Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User Technical - Desktop Tools/Microsoft Word/1-3 Years/End User Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User ADDITIONAL JOB INFORMATION Join an exciting new team and health plan with Aetna Better Health of California! We serve our most vulnerable populations. 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. 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. Job Function: Health CareAetna 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.

Keywords: Aetna, San Diego , Utilization Management Clinical Consultant (RN), Executive , San Diego, California

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