Aetna Behavioral Health Clinical Case Manager in New Albany, Ohio
Req ID: 66056BR
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.
Schedule is Monday-Friday only. One night a week late until 7pm.
Fundamental Components included but are not limited to:
Assessment of Members: Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member s benefit plan and available internal and external programs/services. - Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues. - Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services. Enhancement of Medical Appropriateness and Quality of Care: - Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member s needs to ensure appropriate administration of benefits - Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes - Identifies and escalates quality of care issues through established channels -Ability to speak to medical and behavioral health professionals to influence appropriate member care. - Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health -Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. -Helps member actively and knowledgably participate with their provider in healthcare decision-making -Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member 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 member s goals -Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Qualifications Requirements and Preferences:
3 years of direct clinical practice experience post master s degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
STRONG typist & highly organized with ability to quickly prioritize
Case management and discharge planning experience preferred
Managed care/utilization review experience preferred
Crisis intervention skills preferred
LICENSE required must be independently licensed one of the following:
Mental Health - Licensed Clinical Social Worker, Mental Health - Licensed Independent Social Worker, Mental Health - Licensed Professional Counselor, Mental Health - Licensed Psychologist
Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Direct patient care (hospital, private practice), Clinical / Medical - Disease management, Medical Management - Medical Management - Clinical coverage and policies, Medical Management - Medical Management - Direct patient care
Aetna Application - Aetna Total clinical View, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word
Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment
General Business - Communicating for Impact, Leadership - Collaborating for Results, Technology - Leveraging Technology
Additional Job Information:
Candidate must be independently licensed in the state in which they will be working.
Requires knowledge of mental health and substance abuse disorders.
Must be able to talk on the telephone and type at the same time.
Experience using Motivational Interviewing and good technological skills are a plus.
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.