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Aetna Case Manager RN in Blue Bell, Pennsylvania

Req ID: 64830BR

Job Description

Full time telework opportunity open to candidates across the country.

Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the transplant member's needs and to facilitate the member s overall wellbeing. In doing this the NCM 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. Nurse Case Manager is also responsible for completing utilization reviews on members enrolled in Transplant Case Management. Services strategies policies and programs are comprised of network management and clinical coverage policies

Fundamental Components included but are not limited to:

80% of activities focused on Transplant Case Management;

Interacts with the Provider and Member to achieve optimal outcomes within the benefit plan;

Collaborates with the NME Medical Director for benefit plan guidance and medical determinations;

Manages all aspects of the Transplant member s care including non-transplant related

services to include Utilization Management;

Works with the claims examiner to administer accurate payment per the benefit plan;

Involves Network for LOAs and contracting negotiations/needs

Qualifications Requirements and Preferences:

RN with current unrestricted state licensure required.

Ability to obtain additional RN state licenses required.

5+ years clinical experience required

Case management experience preferred

Transplant and /or critical care experience preferred

Utilization review experience preferred

Computer literate, skilled with Excel, Word and research utilizing the internet

BSN preferred

CCM preferred

Compact RN License a plus; California licensed RN residing in California a plus

Licenses/Certifications:

Nursing - Registered Nurse

Functional Skills:

Nursing - Case Management, Nursing - Concurrent Review/discharge planning, Nursing - Critical Care

Required Skills:

Benefits Management - Understanding Clinical Impacts, General Business - Consulting for Solutions, Leadership - Collaborating for Results

Desired Skills:

Benefits Management - Maximizing Healthcare Quality, Leadership - Driving a Culture of Compliance, Technology - Leveraging Technology

Additional Job Information:

Typical office working environment with productivity and quality expectations Work 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 environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this 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.

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