Aetna Registered Nurse (RN) Case Manager - WV MCD in Charleston, West Virginia
Req ID: 65222BR
Responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member s overall wellness. 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 through integration. Services, strategies, policies and programs are comprised of network management and clinical coverage policies.
Routine field-based travel with personal vehicle is a job requirement. Qualified candidates must have dependable transportation, valid state driver s license and proof of vehicle insurance.
Fundamental Components included but are not limited to:
• Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• Assessments will take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Assessments will include the member s level of work capacity and related restrictions/limitations.
• Application and interpretation of disability criteria and guidelines, applicable policies and procedures, regulatory standards and disability benefit plan to determine eligibility and integration with available internal/external programs.
• Using holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.
• Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Supports, integrates and executes the IHD process.
• Utilizes assessment techniques to assess for integration opportunities and determining work capacity.
• Utilizes interviewing skills to ensure maximum member engagement in disability process and a timely RTW.
Qualifications Requirements and Preferences:
RN with current unrestricted WV state licensure required.
3+ years clinical practice experience required.
Knowledge of community resources and provider networks required.
Familiarity with local health care delivery systems required.
Previous experience conducting face-to-face care management is a plus; qualified candidates must have the ability to support the complexity of members needs including face-to-face visitation.
Availability to work a rotational on-call schedule required.
Case management and discharge planning experience preferred.
Managed Care experience preferred.
Crisis intervention skills preferred.
Behavioral Health experience is a plus.
Nursing - Registered Nurse (RN)
Clinical / Medical - Direct patient care (hospital, private practice), Medical Management - Medical Management - Case Management, Medical Management - Medical Management - Direct patient care
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
Finance - Managing Aetnas Risk, General Business - Applying Reasoned Judgment
General Business - Consulting for Solutions, Leadership - Collaborating for Results, Leadership - Fostering a Global Perspective
Additional Job Information:
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.
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.