Licensed Medicare Appeals Nurse Consultant
Location: Middletown Connecticut
Description: Aetna is hiring Licensed Medicare Appeals Nurse Consultant right now, this career will be placed in Connecticut. More details about this career opportunity kindly see the descriptions. This is a telework role, but candidates must live within commuting distance of an Aetna office. All external candidates must have an active RN license in the state in which they reside.POS! ITION SUMMARY
The Medicare Clinical Appeal Team (MCAT) is part of the National Clinical Appeal Unit, and is charged with the clinical review of Aetna Medicare Advantage Plan members. MCAT nurses and pharmacists work closely with the Medicare Grievance and Appeal Unit (MGAU), providing timely clinical reviews on a diverse range of clinical topics. Each team members work is directly linked to the success of Aetna's Medicare Star Quality Rating system. The MCAT values positive teamwork, independent thinking, problem solving skills, and drive for excellence.
Responsible for the review and resolution of clinical documentation, clinical complaints and appeals of Medicare Advantage Plan members. Reviews documentation and interprets data obtained from clinical records to apply appropriate Medicare - Centers for Medicare & Medicaid Services (CMS) clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Indepen! dently coordinates the clinical resolution with internal/exter! nal clinician support as required. Requires an RN with unrestricted active license.
EDUCATION
The minimum level of education required for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
LICENSES AND CERTIFICATIONSNursing/Registered Nurse (RN), Nursing/Licensed Practical Nurse (LPN), or Nursing/Licensed Vocational Nurse (LVN) is required.FUNCTIONAL EXPERIENCESFunctional - Nursing/Medical-Surgical Care/1-3 YearsFunctional - Nursing/Clinical Claim Review and Coding/1-3 Years
Functional - Clinical/Medical/Concurrent Review/Discharge Planning/1-3 Years
REQUIRED SKILLS
Benefits Management/Interacting with Medical Professionals
Benefits Management/Understanding Clinical Impacts
Leadership/Driving a Culture of Compliance
DESIRED SKILLS
Leadership/Fostering a Global Perspective
Service/Creating a Differentiated Service Experience
Technology/Leveraging Technology
Please note! that benefit eligibility may vary by position. Clickhereto review the benefits associated with this position.
Aetna does not permit the use of tobacco related products or drugs in the workplace.
Job Function: Health Care
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If you were eligible to this career, please email us your resume, with salary requirements and a resume to Aetna.
If you interested on this career just click on the Apply button, you will be redirected to the official website
This career starts available on: Tue, 09 Jul 2013 01:21:10 GMT