Appeals Nurse Consultant

Aetna is a diversified health care benefits companies, providing individuals, employers, health care professionals, producers, and others with innovative benefits, products, and services. It is serving an estimated 46.7 million people with information and resources to help them make better decisions about their health care.

Responsible for the review and resolution of medical policy appeals. Reviews documents and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider appeal issues.

* Reviews complaint/appeal requests and benefit documentation. Considers all previous information (e.g., members medical records, clinical criteria and guidelines) as well as any additional records/data presented to render a recommendation/coverage decision. * Data gathering requires navigation through multiple system applications. * Contacts the provider of record, vendors or internal Aetna departments to obtain additional information * Utilizes clinical knowledge/experience to accurately apply review requirements in rendering clinical decision or when summarizing a case for referral to other clinicians (e.g. Specialty Match Review (SMR). * Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements and ERO eligibility which are required to support the appeals review. * Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals are processed within requirements. * Condenses complex information into a clear and precise clinical picture while working independently * Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs * Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated.

**Background/Experience** * Registered Nurse 3-5 years of clinical experience * Managed care, utilization management or coding & reimbursement experience, preferred * Familiarity with reviewing medical documentation * Must be computer literate to navigate through internal and external systems * Must be able to exercise independent and sound judgment in clinical decision making **Education** The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience. **Licenses And Certifications** Nursing/Registered Nurse is required **Functional Experiences** Functional - Nursing/4-6 Years **Required Skills** * Benefits Management/Understanding Clinical Impacts/ADVANCED * General Business/Applying Reasoned Judgment/ADVANCED * Service/Providing Solutions to Constituent Needs/ADVANCED **Desired Skills** * Leadership/Collaborating for Results/ADVANCED * Service/Handling Service Challenges/ADVANCED **Telework Specifications:** Considered for any US location; training period in the office may be required