Aetna Appeals Nurse Consultant in Rancho Cucamonga, California

Req ID: 45208BR

POSITION SUMMARY

This is an opportunity to join a great team that works well together and learn different types of appeals! The team is supportive and helpful! This is a dynamic fast paced team which reviews clinical appeal issues across different clinical skill competencies (i.e. Med/Surg, Critical Care, Outpatient Services, Medications, Women's Health, etc.)

Responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation 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 issues. Independently coordinates the clinical resolution with internal/external clinician support as required.

Requires a Registered Nurse (RN) with an unrestricted active license.

Fundamental Components:

Responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation 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 issues. Independently coordinates the clinical resolution with internal/external clinician support as required.

Requires an RN with unrestricted active license. 3-5 years of clinical experience and concurrent unrestricted State licensure (RN). Must be computer literate to navigate through internal and external computer systems. Outstanding interpersonal & negotiation skills to effectively establish positive relationships with all constituents both internal and externally. Must be able to exercise independent and sound judgment in clinical decision making. Strong verbal & written communication skills.

Organizational skills, effective time management and ability to manage multiple priorities are a must. Managed care or utilization management experience preferred.

BACKGROUND/EXPERIENCE:

1-3 years of clinical experience; Required

Managed Care experience; Preferred

Knowledge of California HMO plans; Preferred

EDUCATION

The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.

LICENSES AND CERTIFICATIONS

Nursing/Registered Nurse (RN) is Required

FUNCTIONAL EXPERIENCES

Functional - Nursing/Medical-Surgical Care/1-3 Years

Functional - Nursing/Clinical coverage and policies/1-3 Years

Functional - Nursing/Concurrent Review/discharge planning/1-3 Years

Functional - Clinical / Medical/Precertification/1-3 Years

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

Technology/Leveraging Technology/FOUNDATION

Telework Specifications:

Considered for any CA location except within the within the City of Los Angeles city limits; training period in the office may be required.

ADDITIONAL JOB INFORMATION

Dynamic fast paced team which reviews clinical appeals issues across different clinical skill competencies.

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 candidate'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 Care