Utilization Management Nurse Consultant
High Point-4050 Piedmont Parkway
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Position Summary
This Utilization Management (UM) Nurse Consultant role is fully remote and employee can live in any state.
Normal Working Hours:
-8:30am-5:00pm in time zone of residence. Shift times may vary occasionally per the need of the department.
-There is a late shift requirement until 9:00pm EST approximately based on needs of business.
-There is a weekend shift requirement per the needs of the team.
- Holiday rotation per the need of the department (typically 1 holiday per year).
There is no travel expected with this position.
This UM Nurse Consultant position is part of Aetna’s Commercial Care Management division and is part of the dedicated team supporting the membership of plan sponsor.
As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.
- Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
- Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit 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
- Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum …
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Fully remote Must have active RN licensure
Benefits/PerksCommission CVS Health bonus CVS store discount Dental Development courses Disability benefits Discount Programs Education assistance Employee Stock Purchase Employee stock purchase plan Flexible hours Free development courses Full range of medical, dental, and vision benefits Full-time Fully-paid term life insurance Fully remote Healthcare services Holidays Life Insurance Medical Medical, dental, and vision benefits No travel Paid holidays Paid Time Off Short-term incentive program Store discount Term Life Insurance Vacation Vision Vision Benefits Well-being programs
Tasks- Communicate with providers
- Evaluate options
- Facilitate care
- Identify referral opportunities
- Monitor and evaluate options
- Planning
- Render coverage determination
Benefit management Benefit utilization Care management Clinical Clinical Criteria Clinical Experience Clinical expertise Clinical Judgment Collaboration Communication Computer Coverage determination Discharge planning Excel Health care Healthcare Healthcare services Insurance Interpersonal Managed Care Medical necessity Microsoft Office Microsoft Office Suite Organization Organizational Outlook Planning PowerPoint RN RN licensure Telemetry Telephonic Communication Time Management Utilization management Utilization Review Word
Experience2 years
Education Certifications TimezonesAmerica/Anchorage America/Chicago America/Denver America/Los_Angeles America/New_York Pacific/Honolulu UTC-10 UTC-5 UTC-6 UTC-7 UTC-8 UTC-9