Prior Authorization Nurse (LPN/LVN) - KS MCD

Overland Park, KS
United States

Job Description
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Kansas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you'll join a team dedicated to improving the lives of KanCare members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Kansas, and we will support you all the way.

Facilitates the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. Works and provides coverage on weekends and holidays, as assigned.

Requires an unrestricted active Kansas LPN/LVN license.

Fundamental Components:
- Promotes/supports quality effectiveness of Healthcare Services and benefit utilization.
- Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit administration.
- Collects information to support the process of rendering appropriate medical necessity/benefit determinations.
- Identifies members for referral opportunities to integrate with other products, services and/or programs.
- Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations.

Qualification Requirements:
- 2+ years clinical experience required (preferably with a broad-based medical and surgical background.)
- LPN/LVN with current unrestricted Kansas state licensure required.
- Proficiency with computer technology including the Microsoft Office suite and ability to navigate multiple systems required.
- Minimum of 2 years managed care experience strongly preferred.
- Experience and knowledge required in clinical guidelines, systems and tools i.e., MCG, Interqual strongly preferred.
- Behavioral Health experience is strongly preferred.
- Knowledge of community resources and provider networks preferred.
- Familiarity with local health care delivery systems preferred.
- Ability to work and provide coverage on weekends and holidays, as assigned.

The minimum level of education required for candidates in this position is an Associate's degree or equivalent experience.

Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) for State of KS is required.

Functional - Medical Management/Medical Management - Precertification/1-3 Years
Functional - Medical Management/Medical Management - Clinical claim review/1-3 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years
Functional - Clinical / Medical/Precertification/1-3 Years

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

General Business/Applying Reasoned Judgment/FOUNDATION
General Business/Maximizing Work Practices/FOUNDATION
Technology/Leveraging Technology/FOUNDATION

Leadership/Fostering a Global Perspective/FOUNDATION
Leadership/Collaborating for Results/FOUNDATION
Service/Providing Solutions to Constituent Needs/FOUNDATION

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.