Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
Requires an RN with unrestricted active license.
This will be a full-time telework position.
Schedule is Monday-Friday, standard business hours.
Candidates must be located in VA, MD, OH, PA, or Washington D.C.
- 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.
- 3+ years of clinical experience required
- RN with current unrestricted state licensure required
- Post-acute experience preferred
- Managed care experience preferred
- Utilization management experience preferred
Additional Job Information
Typical office working environment with productivity and quality expectationsWork 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 environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.
Associate's degree or equivalent experience
Percent of Travel Required
0 - 10%
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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