Aetna UM Nurse Consultant - RN Behavioral Health 37878BR in Denver, Colorado

Req ID: 37878BR

POSITION SUMMARY

We are seeking individuals that will be a strong contributor to our UM team in the Denver, CO or Rolling Meadows, IL office. Current work at home employees with a compact RN license may apply.

Telephonic Utilization Review nurse with RN degree. Background in psychiatric/ mental health nursing. Ability to multi-task between telephonic reviews and data entry of clinical information.The nurse uses clinical skills to coordinate, document and communicate all aspects of the utilization management program. 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. State or Arkansas or Colorado RN license required.

Fundamental Components:

Perform Medical Necessity review for services requiring preauthorization. These services include but are not limited: to Inpatient, Substance abuse, IP and OP Mental Health& residential treatment. Needs to understand levels of care and how to facilitate/negotiate to lesser level of care when appropriate. Issue notification of determination decisions related to concurrent review determinations. This includes communications to provider, hospital and Member. Meet specific job metrics related to audits scores and daily production.

-Confident in navigating multiple systems, multiple platforms, and being comfortable in switching between technology platforms

-Flexibility working in a rapidly changing environment as the program evolves and develops to meet our customers and members expectations (leveraging the same bullet from the above role)

-Manage multiple priorities and adapt in a fast paced environment. Being responsible for production and quality metrics.

-Confident in oral discussion with external providers to obtain and document clinical information

-Direct providers and members toward in-network steerage

-Gathers clinical information and applies the appropriate clinical guidelines. Policies and procedures clinical judgment to render medical necessity determination.

-Adhere to all URAC accreditation guidelines and regulatory requirements

-Interpret applicable criteria and guidelines while assessing benefits to ensure appropriate administration of those benefits to help support in the development of the members care

-Collaborate with Medical Directors

-Identify and make referrals to Case Management

-Prioritize daily work lists to ensure the requests are completed timely

BACKGROUND/EXPERIENCE:

Managed Care experience preferred. 3-5 years of clinical experience required RN with BH experience

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.

EDUCATION

The highest 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

Nursing/Certified Case Manager is desired

FUNCTIONAL EXPERIENCES

Functional - Nursing/Concurrent Review/discharge planning/4-6 Years

Functional - Nursing/Discharge Planning/4-6 Years

Functional - Nursing/Medical-Surgical Care/4-6 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Outlook/4-6 Years

Technical - Desktop Tools/Microsoft SharePoint/4-6 Years

Technical - Desktop Tools/Microsoft Word/4-6 Years

REQUIRED SKILLS

Benefits Management/Supporting Medical Practice/ADVANCED

General Business/Consulting for Solutions/FOUNDATION

Service/Providing Solutions to Constituent Needs/ADVANCED

Telework Specifications:

WAH available to staff currently working at home - must have compact state RN license.

New employees must be office based in Colorado.

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.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

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Job Function: Health Care