Description: Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.
Fundamental Components: Assessment of Members: Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services. - Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues. - Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services. Enhancement of Medical Appropriateness and Quality of Care: - Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits - Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes - Identifies and escalates quality of care issues through established channels -Ability to speak to medical and behavioral health professionals to influence appropriate member care. - Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health -Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. -Helps member actively and knowledgably participate with their provider in healthcare decision-making -Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs. Monitoring, Evaluation and Documentation of Care: -In collaboration with the member and their care team develops and monitors established plans of care to meet the member's goals -Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures. Background Experience: Unencumbered Behavioral Health license in Kansas; Required 3+ years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility; Required Unencumbered Behavioral Health license in Kansas; Required KanCare Knowledge; Required Crisis intervention skills; Preferred Managed care/utilization review experience; Preferred Case management and discharge planning experience; Preferred Required Skills: Benefits Management - Applying Life Cycle Intelligence, Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts Desired Skills: General Business - Demonstrating Business and Industry Acumen, Service - Working Across Boundaries Functional Skills: Clinical / Medical - Disability, Clinical / Medical - Quality management, Communication - Employee communications Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - TE Microsoft Excel Potential Telework Position: Yes Percent of Travel Required: 50 - 75% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: 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.