Job Description
Job Description
This role is fully telework.
The following hours are required: 8:00am-4:30pm EST with Saturday rotation occasionally required.
This position is for the Aetna One Advocate Unit.
Aetna One Advocate (A1A) is a fully integrated population health and customer service solution for large plan sponsors. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. We are the premiere service and clinical offering for Aetna nation-wide and create industry-leading solutions for our customers and members.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.
- 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
- RN with current unrestricted state licensure required
- 3+ years of clinical practice experience required
Preferred Qualifications
-Previous UM experience
Education
Bachelors degree or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
This role is fully telework.
The following hours are required: 8:00am-4:30pm EST with Saturday rotation occasionally required.
This position is for the Aetna One Advocate Unit.
Aetna One Advocate (A1A) is a fully integrated population health and customer service solution for large plan sponsors. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. We are the premiere service and clinical offering for Aetna nation-wide and create industry-leading solutions for our customers and members.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.
- 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
- RN with current unrestricted state licensure required
- 3+ years of clinical practice experience required
Preferred Qualifications
-Previous UM experience
Education
Bachelors degree or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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