Utilization Management Clinical Nurse Consultant

Are you a highly skilled and compassionate nurse with a passion for improving healthcare outcomes? Aetna is seeking a Utilization Management Clinical Nurse Consultant to join our team and make a meaningful impact on the lives of our members. In this role, you will use your clinical expertise and critical thinking skills to assess medical necessity and ensure appropriate utilization of services. The ideal candidate will possess strong communication and organizational abilities, along with a deep understanding of healthcare regulations and guidelines. Join us in our mission to provide high-quality, cost-effective care to our members. Utilize clinical expertise to evaluate medical necessity and appropriateness of healthcare services for Aetna members. Conduct thorough and timely reviews of medical records, treatment plans, and other relevant information to make informed decisions. Collaborate with healthcare providers to ensure appropriate utilization of services and adherence to evidence-based guidelines. Apply critical thinking skills to identify potential gaps in care and recommend appropriate interventions. Communicate effectively with members and their families, healthcare providers, and internal team members to facilitate optimal care coordination. Adhere to all relevant healthcare regulations, guidelines, and company policies. Maintain accurate and complete documentation of all utilization management activities. Participate in regular team meetings and provide input for process improvement initiatives. Remain up-to-date on industry trends, best practices, and new treatment options. Serve as a resource and mentor for other team members, sharing knowledge and expertise to support their development. Actively contribute to the overall mission of providing high-quality, cost-effective care to Aetna members. Demonstrate compassion, empathy, and sensitivity towards members and their unique healthcare needs. Handle sensitive information with confidentiality and professionalism. Prioritize workload and manage time effectively to meet deadlines and maintain productivity. Continuously evaluate and improve utilization management processes to ensure efficiency and effectiveness. Aetna is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based upon race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.