Description: This role is office based in Phoenix, AZ and requires 25-50% of travel.
Utilizes critical thinking and knowledge of program requirements, network and community resources, and Medicaid benefits to facilitate appropriate physical and behavioral healthcare and social services for members. Provides care coordination, support and education for members through use of care management tools and resources.
Fundamental Components: Evaluation of Members: -Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member's needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services. -Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. - Coordinates and implements assigned care plan activities and monitors care plan progress.
Enhancement of Medical Appropriateness and Quality of Care: - Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes. - Identifies and escalates quality of care issues through established channels. -Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs. - Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote 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.
Monitoring, Evaluation and Documentation of Care: - Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines Background Experience: -2+ years' Case Management experience working with people who have been designated as having a serious mental illness (SMI) required -Experience working with people who are elderly or have a physical disability preferred -A minimum of a Bachelor's Degree is required -Critical areas to succeed- organization, collaboration and time management. Additional Job Information: Authorizes comprehensive home and communitybased and institutional healthcare services to facilitatedelivery of appropriate quality healthcare, promote costeffective outcome and improve program/operationalefficiency involving clinical issues. Exercisesindependent decision making regarding member safety.Case management for long term care members whoreside in Maricopa County. Case Managers travel tomembers' homes and places of residence andcomplete assessments to ensure member safety,medical needs are met and services are provided. Required Skills: Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality Desired Skills: General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance Technology Experience: Desktop Tool - Microsoft Outlook, Operating System - Windows Potential Telework Position: No Percent of Travel Required: 25 - 50% 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.