Req ID: 67901BR Job Description Please note: Candidates must must reside within 1 hour of the Downers Grove, IL office. Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services. Fundamental Components included but are not limited to: Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care(*) Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)(*) Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment(*) Identifies members who may benefit from care management programs and facilitates referral(*) Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization(*) Qualifications Requirements and Preferences: 3+ years of clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required Registered Nurse (RN) with unrestricted state license required Managed care/utilization review experience preferred Knowledge of MCG guidelines preferred Licenses/Certifications: Nursing - Registered Nurse Functional Skills: Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Precertification, Nursing - Clinical coverage and policies, Nursing - Discharge Planning Technology Experience: Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Required Skills: Benefits Management - Interacting with Medical Professionals, Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts Desired Skills: Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts, Service - Handling Service Challenges 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 keyboarding Benefit Eligibility Benefit eligibility may vary by position. Job Function: Healthcare Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.