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Utilization Management Clinical Consultant ID-12238

Are you passionate about improving healthcare outcomes for patients? Do you have experience in utilization management and a strong clinical background? Aetna is seeking a dedicated and knowledgeable Utilization Management Clinical Consultant to join our team. In this role, you will use your clinical expertise to review and assess medical treatments and services, ensuring they are appropriate and cost-effective for our members. As a vital member of our team, you will have the opportunity to make a positive impact on the quality and cost of healthcare. If you are a driven and compassionate individual with a desire to improve the healthcare system, we would love to hear from you. Join us in our mission to build a healthier world, one patient at a time.

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  1. Conduct utilization management reviews and assessments for medical treatments and services to ensure appropriateness and cost-effectiveness for members.
  2. Utilize clinical expertise to make informed decisions and recommendations.
  3. Collaborate with healthcare providers and other team members to gather necessary information for utilization management reviews.
  4. Stay up-to-date on industry trends, guidelines, and regulations related to utilization management.
  5. Use data and analytics to identify opportunities for improvement and cost savings.
  6. Communicate with members and providers regarding utilization management decisions and provide education and support as needed.
  7. Maintain accurate and detailed records of utilization management activities.
  8. Participate in team meetings and contribute to the development of utilization management strategies and processes.
  9. Act as a resource and mentor for less experienced team members.
  10. Advocate for the improvement of healthcare outcomes and cost savings for patients.
  11. Adhere to all company policies and procedures, as well as relevant laws and regulations.
  12. Continuously seek opportunities for personal and professional development to enhance skills and knowledge.
  13. Foster a positive and collaborative work environment.
  14. Represent the company and its values in a professional and ethical manner at all times.

Job Qualifications
Bachelor's Or Master's Degree In Nursing, Healthcare Administration, Or Related Field.

Minimum Of 3-5 Years Of Experience In Utilization Management Or Case Management.

Strong Knowledge Of Healthcare Industry, Including Insurance Regulations And Policies.

Excellent Communication And Interpersonal Skills, With The Ability To Work Collaboratively With A Multidisciplinary Team.

Experience With Data Analysis And Proficiency In Utilizing Electronic Medical Records And Other Healthcare Software.

Required Skills
Quality Assurance

Data Analysis

Case management

Risk assessment

Interpersonal Communication

Clinical documentation

Medical coding

Cost Containment

prior authorization

Utilization Review

Healthcare Regulations

Soft Skills
Communication

Conflict Resolution

Emotional Intelligence

Leadership

Time management

creativity

Critical thinking

Teamwork

Adaptability

Problem-Solving

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