Aetna Field Case Manager - Medical 37210BR in Detroit, Michigan
Req ID: 37210BR
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.
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred members needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating members 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.
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or members 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.
In collaboration with the member and their care team develops and monitors established plans of care to meet the members goals
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
3-5 years of Medical / Surgical experience in a clinical setting
Case management and discharge planning experience preferred
Ability to think critically and creatively problem solve
Certification in case management preferred
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
A license is required for this position
Nursing/Registered Nurse is required
Nursing/Certified Case Manager (CCM) is desired
Functional - Nursing/Medical-Surgical Care/4-6 Years
Functional - Nursing/Case Management/1-3 Years
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Benefits Management/Interacting with Medical Professionals/ADVANCED
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Communicating for Impact/FOUNDATION
Telework considered only for unique circumstances
ADDITIONAL JOB INFORMATION
This role allows the experienced clinician to grow in knowledge, problem solving skills, adult education skills and communication skills as you work with our members to help them achieve the highest level of health possible. We work in a team oriented, multi-disciplinary setting with an emphasis on improving the welfare of our members.
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.
Job Function: Health Care