Aetna Case Manager in Charlottesville, Virginia
Req ID: 47680BR
Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.
Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical and disability needs of the member to facilitate the members overall wellness and appropriate and timely return to work. 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 members overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies.
Fundamental Components & Physical Requirements include 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 members 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 l interviewing skills to ensure maximum member engagement in disability process and a timely RTW.
Exhibits the following Case Manager Behaviors
5+ years clinical practice experience is required
Bilingual in English and Spanish preferred
Behavioral Health background is preferred
Substance Use Disorder treatment background is preferred
The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is required
Functional - Medical Management/Medical Management - Case Management/1+ Years
Functional - Medical Management/Medical Management - Disease management/1+ Years
Functional - Nursing/Mental Health/1+ Years
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
Benefits Management/Understanding Clinical Impacts/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
Employee can transition to telework after training and onboarding and demonstrated competency and comprehension of job role.
ADDITIONAL JOB INFORMATION
Opportunity to work in Fortune 500 and room for advancement within the corporation.
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 candidate'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