Aetna VA MCD Prior Authorization Nurse in Richmond, Virginia

Req ID: 54005BR

Position Summary:

The Prior Authorization Nurse (LPN or LVN) position facilitates the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations.

LPN/LVN with current unrestricted VA state licensure required.

Job Responsibilities:

Promotes/supports quality effectiveness of Healthcare Services and benefit utilization

Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit administration

Collects information to support the process of rendering appropriate medical necessity/benefit determinations

Identifies members for referral opportunities to integrate with other products, services and/or programs

Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations.

Background/ Experience Desired:

Minimum 2+ years clinical experience required with LPN/LVN; Behavioral Health (BH) experience preferred, unrestricted active VA license.

Previous MCO experience or hospital/office prior authorization experience strongly desired

Computer literacy required to navigate through internal/external computer systems, including Microsoft Word and Excel.

Ability to effectively participate in a multi-disciplinary team including internal and external participants.


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

Licenses/ Certifications:

Nursing/Licensed Practical Nurse (LPN) is desired

Nursing/Licensed Vocational Nurse (LVN) is desired

Functional Experiences:

Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years

Clinical / Medical/Precertification/1-3 Years

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

Medical Management/Medical Management - Clinical coverage and policies/1-3 Years

Nursing/Mental Health/1-3 Years

Technology Experiences:

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

Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User

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

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

Additional Job Information:

Experience and knowledge required in clinical guidelines, systems and tools i.e., MCG, Interqual, Broad-based medical and surgical background

Behavioral Health experience is strongly preferred Position may include working on a telephone queue

Knowledge of community resources and provider networks

Familiarity with local health care delivery systems

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

Sedentary work involving periods of sitting, talking, listening.

Work requires sitting for extended periods, talking on the telephone and typing on the computer.

Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

Typical office working environment with productivity and quality expectations.

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. 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.

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.

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.