Aetna Case Manager (RN) Registered Nurse Wood/ Jackson/ Wirt Counties in Charleston, West Virginia
Req ID: 55273BR
Territory: Wood/ Jackson/ Wirt Counties.
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Fundamental Components but not limited to the following:
Assessment of Members:
-Through the use of clinical tools and review of member specific health information/data, conducts comprehensive assessments of referred members needs/eligibility and, in collaboration with the members care team, determines an approach to resolving member issues and/or meeting needs by evaluating the members benefit plan and available internal and external programs/services and resources.
-Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical crisis and refers them to the appropriate clinical and service providers for thorough assessment and treatment, as clinically indicated.
Enhancement of Medical Appropriateness and Quality of Care: - Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits.
Using a holistic approach consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
Ability to speak to medical and behavioral health professionals to influence appropriate member care.
Helps member actively and knowledgeably participate with their provider in healthcare decision-making.
Utilizes negotiation skills to secure appropriate options and services necessary to meet the members benefits and/or healthcare needs.
Monitoring, Evaluation and Documentation of Care:
In collaboration with the member and their care team develops and monitors established plans of care to meet the members goals.
Adheres to care management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
3-5 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 and/or Behavioral Health experience preferred Crisis intervention skills preferred
Proficient computer skills preferred
Obstetrical and/or Behavioral Health experience preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES is required, unrestricted and active:
Nursing/Registered Nurse (RN)
Full-Time Telework (WAH) with 10-25 % travel for face to face visits, Standard business hours. No nights, no weekends or holidays.
ADDITIONAL JOB INFORMATION
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.
Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
Job Function: Health Care
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.