Aetna Clinical Care Manager in Cincinnati, Ohio

Req ID: 41234BR

POSITION SUMMARY

Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.

Fundamental Components:

Assessment of Members:

-Through the use of clinical tools and review of member specific health information/data, conducts comprehensive assessments of referred members needs/eligibility and, in collaboration with the members care team, determines an approach to resolving member issues and/or meeting needs by evaluating the members benefit plan and available internal and external programs/services and resources.

  • Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex clinical indicators which impact care planning and resolution of member issues.

  • Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical crisis and refers them to the appropriate clinical and service 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 care management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits.

  • Using a holistic approach consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives. Presents cases at case rounds/conferences to obtain a multidisciplinary perspective and recommendations 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.

    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 members goals.

  • Adheres to care management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

    BACKGROUND/EXPERIENCE:

    3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

    Case management and discharge planning experience preferred

    Managed Care experience preferred

    EDUCATION:

    The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

    LICENSES AND CERTIFICATIONS

    Nursing/Registered Nurse is required

    FUNCTIONAL EXPERIENCES

    Medical Management/Medical Management - Case Management/1-3 Years

    Nursing/Case Management/1-3 Years

    Clinical / Medical/Disease management/1-3 Years

    Clinical / Medical/Concurrent review / discharge planning/1-3 Years

    Customer Service/Customer Service - Long Term Care/1-3 Years

    REQUIRED SKILLS

    Benefits Management/Interacting with Medical Professionals/ADVANCED

    Benefits Management/Maximizing Healthcare Quality/FOUNDATION

    Benefits Management/Understanding Clinical Impacts/FOUNDATION

    DESIRED SKILLS

    Leadership/Collaborating for Results/ADVANCED

    Leadership/Driving a Culture of Compliance/FOUNDATION

    Technology/Leveraging Technology/FOUNDATION

    Telework Specifications:

    Full -Time (WAH) potential, however required to go out into the field to see members. Staff is required to attend all local and regional meetings.

    ADDITIONAL JOB INFORMATION

    Potential WAH after completing 90 day orientation, on site learning opportunities, opportunities for advancement, excellent benefits and compensation package.

    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. Click here to review the benefits associated with this 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.

Job Function: Health Care