Aetna Appeals Nurse Consultant in Doylestown, Pennsylvania

Req ID: 53950BR

POSITION SUMMARY

Review clinical appeals related to Medicare Advantage Plan members using Center for Medicare and Medicaid Services criteria as well as other criteria

This position is 100% WAH; preferred within 50-mile radius of an Aetna office location.

Fundamental Components:

Review clinical appeals concerning a variety of clinical areas e.g. SNF, radiology, DME Make recommendations to Medical Directors Consult with Medicare coverage guidelines, Clinical Policy Bulletins and MCG

BACKGROUND/EXPERIENCE:

  • 3+ years' clinical experience required

  • Managed Care experience preferred

  • Utilization Management experience preferred

EDUCATION:

The minimum level of education required 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/Concurrent Review/discharge planning/4+ Years

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

REQUIRED SKILLS:

Technology/Leveraging Technology/FOUNDATION

Service/Creating a Differentiated Service Experience/FOUNDATION

DESIRED SKILLS:

Leadership/Driving a Culture of Compliance/FOUNDATION

ADDITIONAL JOB INFORMATION

An opportunity to work with a dynamic team utilizing your clinical experience.

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.