Chicago, IL · On-site
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to ... MUST HAVE UM experience, inpatient utilization management review. * MUST HAVE 1 YEAR OF UTILIZATION ...
Chicago, IL · On-site
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to ... MUST HAVE UM experience, inpatient utilization management review. * MUST HAVE 1 YEAR OF UTILIZATION ...
The Utilization Review (UR) Specialist is a critical member of the administrative team at Advanced ... Knowledge of major insurance provider platforms (e.g., Optum, Aetna, BCBS, Cigna). * Strong ...
The Utilization Review (UR) Specialist is a critical member of the administrative team at Advanced ... Knowledge of major insurance provider platforms (e.g., Optum, Aetna, BCBS, Cigna). * Strong ...
What you will be doing? The Utilization Review (UR) Specialist is a critical member of the ... Knowledge of major insurance provider platforms (e.g., Optum, Aetna, BCBS, Cigna). * Strong ...
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What you will be doing? The Utilization Review (UR) Specialist is a critical member of the ... Knowledge of major insurance provider platforms (e.g., Optum, Aetna, BCBS, Cigna). * Strong ...
Providence, RI · On-site
... Aetna departments to obtain additional information. · Evaluates documentation/information to ... utilization management review. · MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge ...
Providence, RI · On-site
... Aetna departments to obtain additional information. · Evaluates documentation/information to ... utilization management review. · MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge ...
Company Description Aetna is about more than just doing a job. This is our opportunity to re-shape ... Click here to review the benefits associated with this position. Aetna is an equal opportunity ...
Company Description Aetna is about more than just doing a job. This is our opportunity to re-shape ... Click here to review the benefits associated with this position. Aetna is an equal opportunity ...
Company Description Aetna is about more than just doing a job. This is our opportunity to re-shape ... Click here to review the benefits associated with this position. Aetna is an equal opportunity ...
Company Description Aetna is about more than just doing a job. This is our opportunity to re-shape ... Click here to review the benefits associated with this position. Aetna is an equal opportunity ...
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newark, DE · On-site
$85K - $137K/yr
... Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the ... Reviews the admission assessment and collaborates with primary nurse and other health care ...
Newburgh, NY · On-site
$112 - $127/hr
This position manages the medical necessity review process to ensure accurate and timely payment ... Familiarity with processes of critical payers such as Aetna, UHC, MVP, BCBS. Must have experience ...
Newburgh, NY · On-site
$112 - $127/hr
This position manages the medical necessity review process to ensure accurate and timely payment ... Familiarity with processes of critical payers such as Aetna, UHC, MVP, BCBS. Must have experience ...
Aetna is seeking a dynamic and commercially minded Chief Dental Officer to lead the clinical ... Oversee national utilization management, complaints and appeals, and clinical review functions.
Aetna is seeking a dynamic and commercially minded Chief Dental Officer to lead the clinical ... Oversee national utilization management, complaints and appeals, and clinical review functions.
Charlottesville, VA · Remote
Click here to review the benefits associated with this position. Aetna is an equal opportunity ... utilization of available resources, optimal member functioning, and cost-effective outcomes.
Charlottesville, VA · Remote
Click here to review the benefits associated with this position. Aetna is an equal opportunity ... utilization of available resources, optimal member functioning, and cost-effective outcomes.
Charlottesville, VA · On-site
Click here to review the benefits associated with this position. Aetna is an equal opportunity ... utilization of available resources, optimal member functioning, and cost-effective outcomes.
Charlottesville, VA · On-site
Click here to review the benefits associated with this position. Aetna is an equal opportunity ... utilization of available resources, optimal member functioning, and cost-effective outcomes.
$63K - $87K/yr
Join the Aetna Student Health Behavioral Health team and play a key role in ensuring members ... Reviews and analyzes clinical documentation, treatment plans, and progress notes to ensure ...
$63K - $87K/yr
Join the Aetna Student Health Behavioral Health team and play a key role in ensuring members ... Reviews and analyzes clinical documentation, treatment plans, and progress notes to ensure ...
$31.75 - $40.75/hr
Aetna One Advocate is Aetna's premier service and clinical offering for Aetna nation-wide and ... Conducts routine utilization reviews and assessments, applying evidence-based criteria including ...
$31.75 - $40.75/hr
Aetna One Advocate is Aetna's premier service and clinical offering for Aetna nation-wide and ... Conducts routine utilization reviews and assessments, applying evidence-based criteria including ...
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to ... MUST HAVE UM experience, inpatient utilization management review. * MUST HAVE 1 YEAR OF UTILIZATION ...
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to ... MUST HAVE UM experience, inpatient utilization management review. * MUST HAVE 1 YEAR OF UTILIZATION ...
Wichita, KS · On-site
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to ... MUST HAVE UM experience, inpatient utilization management review. * MUST HAVE 1 YEAR OF UTILIZATION ...
Wichita, KS · On-site
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to ... MUST HAVE UM experience, inpatient utilization management review. * MUST HAVE 1 YEAR OF UTILIZATION ...
$21.39 - $25.72
2% of jobs
$25.72 - $30.05
9% of jobs
$33.01 is the 25th percentile. Wages below this are outliers.
$30.05 - $34.38
21% of jobs
The median wage is $37.88 / hr.
$34.38 - $38.70
23% of jobs
$38.70 - $43.03
13% of jobs
$46.39 is the 75th percentile. Wages above this are outliers.
$43.03 - $47.36
10% of jobs
$47.36 - $51.68
8% of jobs
$51.68 - $56.01
5% of jobs
$56.01 - $60.34
5% of jobs
$60.34 - $64.66
2% of jobs
$64.66 - $68.99
2% of jobs
$21
$42
$68
An Aetna Utilization Review job involves assessing medical treatments and services to ensure they are necessary, cost-effective, and align with Aetna's coverage policies. Professionals in this role review patient records, consult with healthcare providers, and apply clinical guidelines to determine appropriate care. They help manage healthcare costs while ensuring patients receive quality treatment. This role typically requires a background in nursing or healthcare and strong analytical skills.
A typical day for an Aetna Utilization Review professional involves reviewing medical records, applying established clinical criteria to determine the medical necessity of services, and collaborating with both healthcare providers and internal teams. You may participate in case discussions, coordinate with physicians, and document determinations in Aetna's systems. The role often involves balancing independent work with frequent team communication, especially when handling complex or appeal cases. This dynamic environment offers opportunities to continually expand your clinical knowledge while making important decisions that impact patient care and cost-effectiveness.
Aetna Utilization Review professionals need a strong clinical background, such as RN licensure or equivalent healthcare qualifications, coupled with a deep understanding of medical necessity criteria and health plan guidelines. Familiarity with utilization management software, electronic health records (EHRs), and systems like InterQual or Milliman is typically required. Strong attention to detail, effective communication, and analytical thinking are soft skills that make candidates excel in this position. These abilities are crucial for ensuring appropriate care determinations, compliance with regulations, and clear communication between providers, patients, and payers.
Cities with the most Aetna Utilization Review job openings:
The most popular types of Aetna Utilization Review jobs are:
States with the most job openings for Aetna Utilization Review jobs include:
The top searched job categories for Aetna Utilization Review jobs are:
Chicago, IL • On-site
Other
Re-posted yesterday
Chicago, IL
Contract
Job Description:
Participates in the development and ongoing implementation of QM Work Plan activities.
Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities:
Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
Data gathering requires navigation through multiple system applications.
Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
Responsible for the review and evaluation of clinical information and documentation.
Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
Independently coordinates the clinical resolution with internal/external clinician support as required.
Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
Prepares and completes QM documents based on interpretation and application of business requirements
Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
Assists in the development and implementation of QM projects and activities
Accountable for completing and implementation of QM Work Plan Activities
Experience:
3+ years of experience as an RN
Registered Nurse in state of residence
Must have prior authorization utilization experience
Experience with Medcompass
Skills:
MUST HAVE MEDCOMPASS or ASSURECARE exp.
MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
MUST HAVE UM experience, inpatient utilization management review.
MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
MUST HAVE 6 months of Prior Authorization.
Education:
Questionnaire:
Do you have experience with Medcompass?
Do you have experience with Prior Authorization?
Do you have experience with Utilization Review?
Do you have an Active Registered Nurse License?
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com) .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.
It services
1,001 - 5,000 Employees
Jersey City, NJ, US
2000
