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Registered Nurse (RN) - Appeals Nurse Consultant - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | los angeles, California |
About this job
This is an exciting full-time opportunity open to candidates in a commutable distance to our High Point NC, Hartford CT, Blue Bell PA, New Albany OH, Dallas TX or Los Angeles CA offices. However, internal candidates currently working from home nationwide may also be considered.
POSITION SUMMARY
Responsible for the review and resolution of medical policy appeals. Reviews documents 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 appeal issues.
Fundamental Components:
Reviews complaint/appeal requests and benefit documentation. Considers all previous information (e.g., members medical records, clinical criteria and guidelines) as well as any additional records/data presented to render a recommendation/coverage decision.
Data gathering requires navigation through multiple system applications.
Contacts the provider of record, vendors or internal Aetna departments to obtain additional information
Utilizes clinical knowledge/experience to accurately apply review requirements in rendering clinical decision or when summarizing a case for referral to other clinicians (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 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.
BACKGROUND/EXPERIENCE desired:
Registered Nurse with 3-5 years of clinical experience required
Managed care, utilization management or coding & reimbursement experience, preferred
Familiarity with reviewing medical documentation
Must be computer literate to navigate through internal and external systems
Must be able to exercise independent and sound judgment in clinical decision making
EDUCATION
The level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is desired
FUNCTIONAL EXPERIENCES
Functional - Nursing//4-6 Years
REQUIRED SKILLS
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
Service/Providing Solutions to Constituent Needs/ADVANCED
DESIRED SKILLS
Leadership/Collaborating for Results/ADVANCED
Service/Handling Service Challenges/ADVANCED
Telework Specifications:
Internals currently WAH may remain telework/WAH; Externals are required to work in the office with a potential to work-from-home after a period of proven performance.
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
Responsible for the review and resolution of medical policy appeals. Reviews documents 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 appeal issues.
Fundamental Components:
Reviews complaint/appeal requests and benefit documentation. Considers all previous information (e.g., members medical records, clinical criteria and guidelines) as well as any additional records/data presented to render a recommendation/coverage decision.
Data gathering requires navigation through multiple system applications.
Contacts the provider of record, vendors or internal Aetna departments to obtain additional information
Utilizes clinical knowledge/experience to accurately apply review requirements in rendering clinical decision or when summarizing a case for referral to other clinicians (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 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.
BACKGROUND/EXPERIENCE desired:
Registered Nurse with 3-5 years of clinical experience required
Managed care, utilization management or coding & reimbursement experience, preferred
Familiarity with reviewing medical documentation
Must be computer literate to navigate through internal and external systems
Must be able to exercise independent and sound judgment in clinical decision making
EDUCATION
The level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is desired
FUNCTIONAL EXPERIENCES
Functional - Nursing//4-6 Years
REQUIRED SKILLS
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
Service/Providing Solutions to Constituent Needs/ADVANCED
DESIRED SKILLS
Leadership/Collaborating for Results/ADVANCED
Service/Handling Service Challenges/ADVANCED
Telework Specifications:
Internals currently WAH may remain telework/WAH; Externals are required to work in the office with a potential to work-from-home after a period of proven performance.
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
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