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Aetna Case Management Nurse (RN) in Erie, Pennsylvania

Req ID: 63535BR

Job Description

Candidates must be located in or near one of the following counties in PA: Mercer, Berks, Lebanon, Erie, Allegheny, or Westmoreland.

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:

RN licensure required

5+ years clinical practice experience required

1+ years case management, home health, OR discharge planning experience required

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

Effective computer skills including navigating multiple systems and keyboarding

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 communications, organizational, and interpersonal skills

Certified Case Manager is preferred


Nursing - Registered Nurse

Additional Job Information:

Although the hiring manager is Anna Dean the role reports directly to Wendi Bognar.

CC 85240

Special Initiative Code: Core-Coventry

Education: Associates with RN


Travel Expectations (Miles per day, member coverage area, time in the field/home/office?)


Productivity Expectations (how many member visits/calls per week?)

• CORE caseload expectations are an engaged average of 50 at all times; 6 mos ramp up time given to get to caseload which begins after national preceptor training; monthly touch points identified to ensure new hires are on track with meeting expectations.

• Cases per day a CORE CM can expect to receive on average would be 5/day.

• Case manager call and documentation audits are performed monthly with a passing expectation (90%).

• Field Case managers are to complete minimally 1-2 face to face visits/wk.



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.