Aetna Clinical Care Manager in Downers Grove, Illinois
Req ID: 37997BR
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
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
3+ 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
Crisis intervention skills preferred
The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is desired
Mental Health/Licensed Clinical Social Worker is desired
Functional - Customer Service//1+ Years
Functional - Medical Management/Medical Management - Case Management/1+ Years
ADDITIONAL JOB INFORMATION
Opportunity for work from home after proven productivity
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