Utilization Management Nurse Consultant

The UM Nurse utilizes their clinical skills along with established criteria to support the coordination, documentation, assessment and communication of medical services and/or benefit administration of specialty cases.
Fundamental components include but are not limited to:
The Special Case Precertification UM Nurse is responsible for the application and/or interpretation of appropriate clinical criteria and guideline policies, procedures, regulatory standards and plan documents. The UM Nurse would interpret relevant medical policy /benefits determinations associated with rare diagnoses, gender reassignment surgery, out of country emergency admissions and other specialty precertifications. The UM nurse will also review for the BRCA genetic testing. This job requires a RN with an unrestricted, active license. A RN that resides in California would be optimal but not a prerequisite for this position. After hours on call will also be required on a rotational basis.
An RN license is required
3-5 years of clinical experience required
Managed Care experience is preferred
3-5 years precert and/or UM experience is preferred
Familiarity with Medicare criteria preferred
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Nursing/Registered Nurse is required
Functional - Nursing/Medical-Surgical Care/4-6 Years
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
General Business/Turning Data into Information/FOUNDATION
Technology/Leveraging Technology/FOUNDATION
Benefits Management/Interacting with Medical Professionals/ADVANCED
General Business/Applying Reasoned Judgment/ADVANCED
General Business/Consulting for Solutions/FOUNDATION
This is an opportunity to work with members who require specialized care / treatment that can only be provided by a select number of providers or facilities due to a rare diagnosis; members who are traveling outside of the United States and require an emergency medical admission and/or evacuation; and members who are seeking gender reassignment surgery along with other specialized services.
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.
Employment Type Regular Career Band Description Professional

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