Aetna Case Management Coordinator Texas in Amarillo, Texas
Req ID: 67455BR
Full time telework opportunity open to candidates in Texas.
Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.
Fundamental Components included but are not limited to:
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 and company policies and procedures.
Qualifications Requirements and Preferences:
2+ years experience in behavioral health, social services or appropriate related field equivalent to program focus required
Bachelor's degree or non-licensed master level clinician required
Case management and discharge planning experience preferred
Managed Care experience preferred
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
Benefits Management - Encouraging Wellness and Prevention, General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results
Benefits Management - Interacting with Medical Professionals, General Business - Communicating for Impact, Leadership - Driving a Culture of Compliance
Benefit eligibility may vary by position.
Job Function: Healthcare
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.