ZipRecruiter

Log In

1

Manager Aetna Utilization Review Jobs in Puerto Rico

Biosimilar Sciences PR LLC

PR · On-site

Oversee vendor qualification and validation service providers Digital Enablement & AI Utilization ... review * Ensure responsible and compliant use of AI technologies in alignment with cGMP, data ...

Marriott International

Accounting & Cost Manager

Dorado, PR · On-site

$78K - $102K/yr

... utilization of financial resources. Demonstrating and Applying Accounting Knowledge • ... reviewed and maintained prior to approval of vendor setup and modifications. • Manages and ...

Marriott

PR · On-site

$78K - $102K/yr

... and utilization of financial resources. Demonstrating and Applying Accounting Knowledge ... Reviews approved purchases orders, and signature approval from receiving and department heads on ...

Marriott

Accounting & Cost Manager

Dorado, PR

$78K - $102K/yr

... and utilization of financial resources. Demonstrating and Applying Accounting Knowledge ... Reviews approved purchases orders, and signature approval from receiving and department heads on ...

chicosfas

Assistant Store Manager - Soma

San Juan, PR · On-site

... sheet review and payroll accuracy documents, and merchandise flow processes. * Performs all ... Ensures team maintains consistent client communication through utilization of customer book ...

Journeys

Store Manager Puerto Rico

Ponce, PR · On-site

Conduct monthly performance reviews * Recognize talented staff and develop them for growth within ... Genesco's employment practices will continue to be directed toward full utilization of all ...

Journeys

Store Manager Puerto Rico

Ponce, PR · On-site

Conduct monthly performance reviews * Recognize talented staff and develop them for growth within ... Genesco's employment practices will continue to be directed toward full utilization of all ...

Genesco

PR · On-site

Conduct monthly performance reviews * Recognize talented staff and develop them for growth within ... Genesco's employment practices will continue to be directed toward full utilization of all ...

previous pagenext page

Showing results 21-40

All JobsAetna Utilization Review JobsManager Aetna Utilization Review JobsManager Aetna Utilization Review Jobs in Puerto Rico

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

Program Manager

US Department of the Treasury

San Juan, PR • On-site

$125K/yr

Full-time

Posted 7 days ago

U.S. Department Of The Treasury rating

8.2

Company rating: 8.2 out of 10

Based on 13 frontline employees who took The Breakroom Quiz

310th of 844 rated public administrative organizations

Job description

WHAT IS THE LARGE BUSINESS & INTERNATIONAL DIVISION? A description of the business units can be found at: https://www.jobs.irs.gov/about/who/business-divisions
  • Position(s) are to be filled in following area(s):
    • LBI - Strategic Programs

REVIEW THE ADDITIONAL INFORMATION BELOW FOR FURTHER DETAILSQualifications:

Federal experience is not required. Experience may have been gained in the public sector, private sector or through Volunteer Service. One year of experience refers to full-time work; part-timework is considered on a prorated basis. To ensure full credit for your work experience, please indicate dates of employment by month/day/year, and indicate number of hours worked per week, on your resume.
SPECIALIZED EXPERIENCE IR-1: To be minimally qualified for this position you must have at least one (1) year of specialized experience equivalent to the next lower-level payband or GS grade in the normal line of progression.
Specialized experience would include one year of substantive supervisory or program management experience at the GS-13 or GS-14 level or equivalent level manager or comparable management or leadership experiences outside of Federal service.
To be qualifying for this position your experience should be sufficient to demonstrate:

  • Experience leading strategic planning initiatives by evaluating legislative proposals, organizational priorities, policy changes, and emerging program issues; developing implementation strategies and long-range plans that support organizational objectives and mission requirements.
  • Experience analyzing program operations, organizational performance, workload data, resource utilization, operational risks, and program outcomes; identifying issues and developing recommendations that improve operational effectiveness, efficiency, and program performance.
  • Experience developing performance measures, evaluation criteria, and accountability processes used to monitor program accomplishments, assess organizational performance, evaluate results, and recommend operational improvements.
  • Experience preparing executive reports, briefing materials, written documentation, analytical studies, and recommendations that communicate complex findings, support organizational planning, and facilitate management decision-making.
  • Experience planning, coordinating, monitoring, and evaluating multiple projects or organizational initiatives involving competing priorities, changing requirements, resource constraints, and cross-functional stakeholders to achieve strategic program objectives.
  • Experience conducting operational research by evaluating program data, identifying organizational trends, assessing the impact of proposed changes, and developing evidence-based recommendations that improve program operations, policy implementation, or organizational performance.
  • Experience interpreting Federal tax laws, regulations, Internal Revenue Service program requirements, compliance guidance, and related policies to evaluate program impacts, resolve technical issues, develop recommendations, and support implementation of organizational initiatives.
  • Experience evaluating financial information, budget data, staffing requirements, workload trends, and resource utilization to develop recommendations that support strategic planning, operational priorities, and effective allocation of organizational resources.

AND

You must also meet the following requirement(s):
  • TIME AFTER COMPETITIVE APPOINTMENT (TACA): By the closing date (or if this is an open continuous announcement, by the cut-off date) specified in this job announcement, current civilian employees must have completed at least 90 days of federal civilian service since their latest non-temporary appointment from a competitive referral certificate, known as time after competitive appointment. For this requirement, a competitive appointment is one where you applied to and were appointed from an announcement open to "All US Citizens".

For more information on qualifications please refer to OPM's Qualifications Standards.
Go to Understanding the IRS Paybands for GS/IR conversion.

Education:A college or university degree generally must be from an accredited (or pre-accredited) college or university recognized by the U.S. Department of Education. For a list of schools which meet these criteria, please refer to Department of Education Accreditation page.
FOREIGN EDUCATION: Education completed in foreign colleges or universities may be used to meet the requirements. You must show proof the education credentials have been deemed to be at least equivalent to that gained in conventional U.S. education program. It is your responsibility to provide such evidence when applying. Click here (Section 3, Explanation of Terms) or here for Foreign Education Credentialing instructions.
We recommend choosing an evaluator from a member organization of one of the following national associations of credential evaluation services: National Association of Credential Evaluation Services (NACES) or Association of International Credentials Evaluators (AICE).Employment Type: OTHER

What U.S. Department Of The Treasury employees say

Pay

Hours and flexibility

Workplace

Get the full story on Breakroom

Apply