A1A Precertification Utilization Management Nurse Consultant

CVS Health
New Albany, Ohio
Jun 16, 2021
Jun 24, 2021
Case Management
Contract Type
Job Description
This position is temporarily work from home. Once COVID restrictions are lifted, this role will be office based in New Albany, OH.

Required hours are Monday- Friday 8:00am-4:30pm EST with evening rotation required about 2 times a month until 8pm.

Precertification Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management 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.

What is 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.

Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
* Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.
* Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
* Reviews prior claims to address potential impact on current case management and eligibility.
* Assessments include the member’s level of work capacity and related restrictions/limitations.
* Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.
* Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management.
* Utilizes case management processes in compliance with regulatory and company policies and procedures.

Required Qualifications
* RN with current unrestricted state licensure required
* 3+ years of clinical practice experience required

Preferred Qualifications
*Managed care experience preferred
*Utilization management preferred
*Precertification experience preferred

Bachelors degree or equivalent experience

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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