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Job Information

Aetna Utilization Management Clinical Consultant (RN) in Phoenix, Arizona

Req ID: 66427BR

Job Description

This role is office based in Phoenix, AZ with the potential to work at home following successful training.

Utilizes critical thinking and knowledge of program requirements, network and community resources, and Medicaid/Medicare benefits to facilitate appropriate physical and behavioral healthcare and social services for members. 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.

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 included 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

Qualifications Requirements and Preferences:

  • An RN license is required

  • 3+ years of clinical practice experience required

  • Behavioral/Mental Health experience strongly preferred

  • Managed care/utilization review experience preferred

Licenses/Certifications:

Nursing - Registered Nurse, Nursing - Registered Nurse (RN)

Functional Skills:

Nursing - Clinical coverage and policies, Nursing - Concurrent Review/discharge planning, Nursing - Critical Care, Nursing - Medical-Surgical Care, Nursing - Mental Health

Technology Experience:

Aetna Application - Milliman, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Required Skills:

Benefits Management - Interacting with Medical Professionals, Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts

Desired Skills:

Benefits Management - Maximizing Healthcare Quality, Service - Case Administration, Service - Handling Service Challenges

Additional Job Information:

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.

Sedentary work involving periods of sitting, talking and listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as the PC monitor.

Benefit Eligibility

Benefit eligibility may vary by position.

Job Function: Healthcare

Aetna 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.

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