Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.
Schedule is Monday-Friday standard business hours. After training their is a rotation of weekends on call and holidays.
Position is onsite in New Albany, OH.
Aetna is an Equal Opportunity, Affirmative Action Employer
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care() Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)() Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment() Identifies members who may benefit from care management programs and facilitates referral() Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization(*)
Managed care/utilization review experience preferred
3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Registered Nurse (RN) with unrestricted state license.
Benefit eligibility may vary by position.
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