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 of care

- Communicates with providers and other parties to facilitate care/treatment

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

- Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Required Qualifications

- Must have active current and unrestricted RN licensure in state of residence

- 2+ years of clinical experience as an RN (all clinical areas considered: Home Health, Med/Surg, Telemetry, ICU, NICU, Long term care, orthopedics, and more)

- Must be able to work Monday through Friday 8:30am-5:00pm in time zone of residence. Shift times may vary occasionally per the need of the department.

- Must be able to work a late shift requirement until 9:00pm EST based on needs of business

- Must be able to work a weekend shift requirement per the needs of the team.

- Must be able to work Holiday rotation per the need of the department (typically 1 holiday per year). 

- 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)

Preferred Qualifications
- 1+ years’ experience Utilization Review experience

- 1+ years’ experience Managed Care

- Strong telephonic communication skills

- Experience with computers toggling between screens while using a keyboard and speaking to customers.

- Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills

- Ability to manage multiple priorities, effective organizational and time management skills required

- Ability use a computer station and sit for extended periods of time

Education

Associates degree required

BSN preferred