UM Nurse Consultant

Overview

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

Must reside within 45 miles to office locations in New Albany OH, Chandler AZ or High Point NC.

Precertification Nurse Case Manager is responsible for reviewing medical records to determine the medical necessity for elective procedures. They are responsible for communicating the current status and determinations to our providers and members, as well as guide the members, through the health care system. They assess the members conditions and coordinate care with our care management team, telephonically assessing, planning, implementing and coordinating activities with members to evaluate the medical needs of the member, to facilitate the member’s overall wellness.

Services strategies, policies and programs are comprised of network management and clinical coverage policies.

A1A

Aetna One Advocate is Aetna’s premier service and clinical offering for Aetna nation-wide and creates industry-leading solutions for our customers and members. The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services. Our mission is to meet each member at every aspect of their health care journey.

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. This is an exciting time to join Aetna a CVS Health company in our journey to change the way healthcare is delivered today.

We are health care innovators.

Fundamentals

• Evaluates benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• Reviews for plan nuances and requirements including (institute of quality) IOQ requirements, benefit exclusions, second opinion requirements and claims history to address potential impact on current case review and eligibility.
• Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
• Conducts routine utilization reviews and assessments, applying evidence-based criteria including internal clinical policy bulletins (CPB) and Milliman care guideline (MCG) and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services related to elective procedures.
• Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
• Strategizes clinical review, prioritizing various items including escalations, dates of services and case type to maintain standard timeliness guidelines.
• Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Monitoring for high cost claims and need for additional support from the health care team.
• Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
• Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
• Reviews for accurate level of care and…