Sep 20, 2019
Aetna Description: Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies. 64417 Fundamental Components: Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member's level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. Also performs Utilization Management for inpatient/SNF/Acute Rehab/NICU/Peds using MCG criteria. Background Experience: Case Management in an integrated model preferred Bilingual preferred 3+ years clinical practice experience Utilization Management Review experience preferred RN with current unrestricted state licensure required Additional Job Information: Typical office working environment with productivity and quality expectationsWork requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written. Required Skills: Benefits Management - Maximizing Healthcare Quality, General Business - Demonstrating Business and Industry Acumen, Leadership - Driving a Culture of Compliance Desired Skills: Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment, General Business - Communicating for Impact Functional Skills: Management - Management - Health Care Delivery, Medical Management - Medical Management - Hospital, Nursing - Case Management, Nursing - Concurrent Review/discharge planning Technology Experience: Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Education: Nursing - Registered Nurse (RN) Potential Telework Position: Yes Percent of Travel Required: 0 - 10% 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.
Professional Diversity Network Mesa, AZ, USA Full-Time