Appeals Nurse Consultant

Job Description

Description: This full time position is part of a team of a number of Complaint and Appeal Nurse Analysts and Complaint and Appeal Analysts. Our team provides comprehensive post-service utilization management review for providers. Part of our team also reviews cases that are DRG PrePay contracts. All of our Complaint and Appeal Nurse Analysts are provided on the job training, and work collaboratively with a preceptor.

65578

Fundamental Components: Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins. Review clinical appeals from participating inpatient and outpatient Medicare Advantage providers. Make medical necessity recommendations based on industry standards, MCG or InterQual guidelines; CMS Guidelines, or Aetna Clinical Policy Bulletins. Exposure to a wide variety of clinical appeal issues. • Review post service Legacy Aetna and Legacy Coventry provider appeal requests. • Collaborate with Aetna medical directors. • Become a subject matter expert with regard to the Centers for Medicare & Medicare Services Guidelines, Industry medical necessity guidelines of MCG and/or InterQual. • Contribute to Aetna’s strong Medicare star quality ratings. Background Experience: 3+ years of clinical experience; Required
Managed Care experience; Preferred
Appeals or Utilization Management experience; Preferred
RN with current unrestricted state licensure; Required Additional Job Information: Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.
Category: Functional-Nursing Area of focus-Medical-Surgical Care yrs of exp-1-3 yrs. Functional-Clinical Medical-Area of focus-Concurrent review/discharge planning 1-3 yrs exp: Coding experience preferred.
Required Skills: Leadership - Driving a Culture of Compliance, Service - Creating a Differentiated Service Experience, Technology - Leveraging Technology Functional Skills: Medical Management - Medical Management - Case Management, Medical Management - Medical Management - Hospital, Nursing - Concurrent Review/discharge planning Education: Nursing - Registered Nurse Potential Telework Position: Yes Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: 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.