Job Description
Job Description
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 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
- Ability to demonstrate and explain past experience delivering exemplary customer service for both internal and external customers required
- 3-5 years of clinical experience required
- RN with current unrestricted state licensure required.
- Weekend/holiday coverage will occasionally be required.
- Requires 1130am-800pm shift for at least first 12 months post completion of orientation period and work in clinical telephone queue working with providers to secure additional information for prior authorization review.
Preferred Qualifications
- Managed Care experience preferred
- Prior demonstrated experience working in a high volume clinical call center environment preferred
- Utilization Management experience preferred.
Education
Bachelor's 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.
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 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
- Ability to demonstrate and explain past experience delivering exemplary customer service for both internal and external customers required
- 3-5 years of clinical experience required
- RN with current unrestricted state licensure required.
- Weekend/holiday coverage will occasionally be required.
- Requires 1130am-800pm shift for at least first 12 months post completion of orientation period and work in clinical telephone queue working with providers to secure additional information for prior authorization review.
Preferred Qualifications
- Managed Care experience preferred
- Prior demonstrated experience working in a high volume clinical call center environment preferred
- Utilization Management experience preferred.
Education
Bachelor's 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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