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Registered Nurse (RN) - Utilization Management (UM) Nurse Consultant - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | sandy, Utah |
About this job
The precertification nurse position offers the opportunity to utilize the broad spectrum of nursing knowledge and experience to help facilitate quality and evidence based medical care.
POSITION SUMMARY
The Precertification Nurse works as part of a team that performs precertification of specified health care services to determine medical necessity. The nurse evaluates requests by applying approved criteria and guidelines to help ensure quality and appropriate health care services for the member working collaboratively as needed with providers and the medical directors as indicated.
Fundamental Components:
Applies clinical criteria and coverage guidelines in order to determine medical necessity of services requiring precertification. 50%
Evaluates requested services determining coverage, provider participation in the network, and benefits for the service requested. 10%
Works with requesting providers to obtain medical records and data to complete reviews. 10%
Collaborates with medical directors and other clinical service staff to complete reviews in a timely and accurate manner in compliance with regulaory requirements. 10%
Works with other departments to resolve claim issues related the authorization processes. 10%
Completes work within the framework of the Aetna Way in an ethical and compliant manner. 10%
BACKGROUND/EXPERIENCE desired:
RN with current unrestricted licensure required
3-5 years of clinical nursing experience required
Managed Care experience preferred
Understanding of ICD-9-CM, CPT and HCPCS coding a plus.
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 is required
Managed Care/Certified Managed Care Nurse, CMCN is desired
Information Technology/Certified Professional Coder (CPC) is desired
FUNCTIONAL EXPERIENCES
Functional - Nursing/Medical-Surgical Care/4-6 Years
Functional - Nursing/Skills Progression-Command/4-6 Years
Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years
TECHNOLOGY EXPERIENCES
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
REQUIRED SKILLS
Benefits Management/Supporting Medical Practice/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
DESIRED SKILLS
General Business/Applying Reasoned Judgment/ADVANCED
Service/Providing Solutions to Constituent Needs/ADVANCED
Telework Specifications:
full time telework; training period in the office may be required for if lives in local area
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.
We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Employment Type Regular Career Band Description Professional
POSITION SUMMARY
The Precertification Nurse works as part of a team that performs precertification of specified health care services to determine medical necessity. The nurse evaluates requests by applying approved criteria and guidelines to help ensure quality and appropriate health care services for the member working collaboratively as needed with providers and the medical directors as indicated.
Fundamental Components:
Applies clinical criteria and coverage guidelines in order to determine medical necessity of services requiring precertification. 50%
Evaluates requested services determining coverage, provider participation in the network, and benefits for the service requested. 10%
Works with requesting providers to obtain medical records and data to complete reviews. 10%
Collaborates with medical directors and other clinical service staff to complete reviews in a timely and accurate manner in compliance with regulaory requirements. 10%
Works with other departments to resolve claim issues related the authorization processes. 10%
Completes work within the framework of the Aetna Way in an ethical and compliant manner. 10%
BACKGROUND/EXPERIENCE desired:
RN with current unrestricted licensure required
3-5 years of clinical nursing experience required
Managed Care experience preferred
Understanding of ICD-9-CM, CPT and HCPCS coding a plus.
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 is required
Managed Care/Certified Managed Care Nurse, CMCN is desired
Information Technology/Certified Professional Coder (CPC) is desired
FUNCTIONAL EXPERIENCES
Functional - Nursing/Medical-Surgical Care/4-6 Years
Functional - Nursing/Skills Progression-Command/4-6 Years
Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years
TECHNOLOGY EXPERIENCES
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
REQUIRED SKILLS
Benefits Management/Supporting Medical Practice/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
DESIRED SKILLS
General Business/Applying Reasoned Judgment/ADVANCED
Service/Providing Solutions to Constituent Needs/ADVANCED
Telework Specifications:
full time telework; training period in the office may be required for if lives in local area
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.
We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Employment Type Regular Career Band Description Professional