Appeals Nurse Associate Job Opening

Description:
Responsible for the review and resolution of clinical complaints and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.62343

Fundamental Components:
Assists with reviewing complaint / appeal requests of all clinical determinations/clinical policies. Considers all previous information as well as any additional records/data presented to prepare a recommendation. Assists with data gathering that requires navigation through multiple system applications. Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.). 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 determinations. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination. Seeks guidance from other healthcare professionals in the coordination and administration of the appeals process

Background Experience:
2 years of clinical experience required
Managed Care experience preferred

LICENSE
LPN/LVN with current unrestricted state licensure required and must be active.

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.

Potential Telework Position:
No

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests