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Aetna Workers Compensation Field Case Manager RN in Boston, Massachusetts

Req ID: 67608BR

Job Description

The Case Manager uses a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual s and family s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.

Fundamental Components included but are not limited to:

  • Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.

  • Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.

  • Interacts with members/clients telephonically or in person.

  • May be required to meet with members/clients in their homes, work-sites, or physician s office to provide ongoing case management services.

  • Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate.

  • Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.

  • Prepares all required documentation of case work activities as appropriate.Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.

  • Provides educational and prevention information for best medical outcomes.

  • Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. Testifies as required to substantiate any relevant case work or reports.

  • Conducts an evaluation of members/clients needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.

  • Utilizes case management processes in compliance with regulatory and company policies and procedures.

  • Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.

  • 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/client s overall wellness through integration.

  • Monitors member/client progress toward desired outcomes through assessment and evaluation.

Qualifications Requirements and Preferences:

Required Skills/Experience:

  • 3+ years clinical practice experience

  • Registered Nurse with active state license in good standing in the state where job duties are performed

  • Ability to travel within a designated geographic area for in-person case management activities

  • Excellent analytical and problem solving skills

​- Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications

  • Effective computer skills including navigating multiple systems and keyboarding

  • Associate's degree in Nursing

Preferred Skills/Experience:

  • Bilingual preferred

  • 3+ years of case management experience

  • Ability to work independently

  • Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM)

  • Knowledge of laws and regulations governing delivery of rehabilitation services.

  • Effective communications, organizational, and interpersonal skills.

  • Job-specific technical knowledge (e.g., knowledge of workers compensation and disability industry for workers compensation case managers or case management)

  • Bachelor's and/or Master's degree in Nursing or related field

Licenses/Certifications:

Nursing - Registered Nurse (RN)

Functional Skills:

Clinical / Medical - Disability

Technology Experience:

Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word

Benefit Eligibility

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.

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