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Manager Aetna Utilization Review Jobs in Puerto Rico

Encompass Health

Case Manager

Manati, PR · On-site

$17 - $21.75/hr

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * License or ...

Encompass Health

Case Manager

Manati, PR

$17 - $21.75/hr

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * License or ...

UHS

PR

The Clinical Manager (CLM) of the Behavioral Health Contact Center is responsible for the depth of ... Provide backup to Utilization Review Department out of business hours including document in the ...

OncoHealth

Case Review Representative

Guaynabo, PR · On-site +1

$13 - $15/hr

About the Role The Case Review Representative serves as a one-stop shop and intake of all calls ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

OncoHealth

Case Review Representative

Guaynabo, PR · On-site

About the Role The Case Review Representative serves as a one-stop shop and intake of all calls ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

OncoHealth

Case Review Specialist - PR

Guaynabo, PR · On-site

About the Role The Case Review Specialist ensures that case documentation is provided by the ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

OncoHealth

Case Review Specialist - PR

Guaynabo, PR · On-site +1

About the Role The Case Review Specialist ensures that case documentation is provided by the ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

US Department of the Treasury

Program Manager

Ponce, PR · On-site

$125K/yr

LBI - Strategic Programs REVIEW THE ADDITIONAL INFORMATION BELOW FOR FURTHER DETAILS Qualifications ... utilization, operational risks, and program outcomes; identifying issues and developing ...

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Manager Aetna Utilization Review information

What does a manager in Aetna Utilization Review do?

A Manager of Aetna Utilization Review oversees the process of evaluating medical necessity, appropriateness, and efficiency of healthcare services for Aetna-insured members. They manage a team of utilization review nurses or specialists who review patient records and coordinate with healthcare providers to ensure compliance with Aetna’s policies. Their main goal is to ensure patients receive necessary care while controlling costs and preventing unnecessary treatments. Additionally, they may handle appeals, train staff, and implement process improvements.

What key skills and qualifications are needed to thrive as a manager in Aetna Utilization Review?

To thrive as a Manager in Aetna Utilization Review, you need a strong background in healthcare management, clinical knowledge (often as an RN or similar licensure), and experience with utilization review processes. Familiarity with case management software, medical coding systems, and compliance with regulatory requirements such as NCQA or URAC is typically expected. Leadership, decision-making, and communication skills are crucial for effectively guiding teams and collaborating with providers. These competencies ensure efficient care coordination, regulatory compliance, and high-quality patient outcomes in a complex healthcare environment.

How does a manager in Aetna Utilization Review typically collaborate with clinical teams and other departments to ensure effective patient care?

A Manager of Aetna Utilization Review works closely with clinical teams, case managers, and other departments to coordinate care and ensure that medical services are necessary and meet established guidelines. This role often involves reviewing patient cases, providing guidance on coverage decisions, and facilitating clear communication between healthcare providers and insurance representatives. Regular meetings and case discussions help to resolve complex cases and optimize patient outcomes. Effective collaboration is key to balancing cost efficiency with quality care, and managers are expected to foster a supportive environment that encourages teamwork and continuous improvement.

What is the difference between Manager Aetna Utilization Review vs Utilization Review Nurse?

AspectManager Aetna Utilization ReviewUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or ANCC, and management experienceRegistered Nurse (RN) license, relevant certifications
Work EnvironmentSupervises utilization review teams, collaborates with healthcare providers, and manages case reviewsConducts patient case assessments, reviews medical records, and makes utilization decisions
Employer & Industry UsageCommonly employed by insurance companies like Aetna, healthcare organizations, and managed care firmsUsed within insurance companies, healthcare facilities, and third-party review organizations

The main difference is that the Manager Aetna Utilization Review oversees the review process and manages teams, while the Utilization Review Nurse focuses on conducting case assessments and medical reviews. Both roles require nursing credentials, but the manager position involves leadership and administrative responsibilities.

What are popular job titles related to Manager Aetna Utilization Review jobs in Puerto Rico? For Manager Aetna Utilization Review jobs in Puerto Rico, the most frequently searched job titles are:
What job categories do people searching Manager Aetna Utilization Review jobs in Puerto Rico look for? The top searched job categories for Manager Aetna Utilization Review jobs in Puerto Rico are:
Manager Aetna Utilization Review jobs near you

Utilization Coordinator

San Juan Capestrano

San Juan, PR

Full-time

Re-posted 26 days ago

Job description

Overview

PURPOSE STATEMENT: 

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.  

Responsibilities

ESSENTIAL FUNCTIONS: 

  • Act as liaison between managed care organizations and the facility professional clinical staff. 
  • Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements. 
  • Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.  
  • Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office. 
  • Conduct quality reviews for medical necessity and services provided.   
  • Facilitate peer review calls between facility and external organizations.  
  • Initiate and complete the formal appeal process for denied admissions or continued stay.  
  • Assist the admissions department with pre-certifications of care.  
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates. 

OTHER FUNCTIONS:  

  • Perform other functions and tasks as assigned. 
Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: 

  • Required Education: High school diploma or equivalent. 
  • Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field. 
  • Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred 

LICENSES/DESIGNATIONS/CERTIFICATIONS:  

  • Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services. 
  • CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.   
  • First aid may be required based on state or facility requirements. 

 

ADDITIONAL REGULATORY REQUIREMENTS: 

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances  (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate. 

We are committed to providing equal  employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.

Employment Type: FULL_TIME

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