Aetna Utilization Management Nurse Consultant (RN) in Blue Bell, Pennsylvania

Req ID: 53957BR

Required hours are Monday-Friday working 8:00am-4:30pm EST and 1 day of 9:30am-6pm EST

A candidate external to Aetna will need to be office based in Houston, TX or Blue Bell, PA.

POSITION SUMMARY

The Nurse Consultant utilizes clinical skills to review complex benefits, and apply plan and CPB criteria. You will work closely with our dedicated Medical Directors for members seeking precertification for Infertility services. This role involves review of clinical records and outreach to providers and members to facilitate optimal utilization of Infertility benefits.

Fundamental components include but are not limited to:

Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, and procedure to make coverage determination/Medical Director recommendations.

Communicates with providers and other parties to facilitate care/treatment

Identifies members for referral opportunities to integrate with other programs

Identifies eligibility for benefit utilization and maximizing available benefits.

Consults and lends expertise to other internal and external constituents in the coordination and administration of the Infertility benefits.

BACKGROUND/EXPERIENCE

An RN license is required

Infertility experience preferred

3-5 years of clinical experience required

Managed Care / UM experience preferred

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

FUNCTIONAL EXPERIENCES

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

Functional - Nursing/OB/GYN/1-3 Years

TECHNOLOGY EXPERIENCES

Technical - Aetna Applications/Aetna Total clinical View/1-3 Years/End User

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

Service/Providing Solutions to Constituent Needs/ADVANCED

Technology/Leveraging Technology/FOUNDATION

DESIRED SKILLS

General Business/Applying Reasoned Judgment/ADVANCED

Leadership/Collaborating for Results/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

Telework Specifications:

Full-Time Telework, any US location

ADDITIONAL JOB INFORMATION

This is an exciting opportunity to help our members become parents. It is a challenging and quickly changing clinical field. We are a small team that works closely with dedicated Medical Directors.

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 candidates'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

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.