Aetna Case Manager RN in New Albany, Ohio
Req ID: 51037BR
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.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex clinical indicators which impact care planning and resolution of member issues.
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. 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 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. Presents cases at case rounds/conferences to obtain a multidisciplinary perspective and recommendations 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.
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, policies, and procedures.
3+years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Registered Nurse (RN) is required
Must be comfortable completing home / face to face visits with members
Case management and discharge planning experience preferred
Managed Care experience preferred
Crisis intervention skills preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is required
Functional - Clinical / Medical/Disease management/4-6+ Years
Functional - Nursing/Case Management/4-6+ Years
This position is a full time position.
Staff person will report to the office for the during the entire orientation period, following the orientation period, the staff person will migrate to the his/her home office.
ADDITIONAL JOB INFORMATION
We have a comprehensive training program, following your orientation period you will migrate to your home office furnished by the MCO. We have great benefits and this is a great team!
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