Aetna Registered Nurse Case Manager in New Albany, Ohio

Req ID: 52163BR

Please note: This is a full time, work at home position that can be worked anywhere in the US. Candidates must be comfortable working 8AM-5PM ET.

POSITION SUMMARY

Nurse Case Manager (NCM) is responsible for assessing members face-to-face and telephonically; and planning, implementing and coordinating all case management activities with members to evaluate the appropriate holistic needs (physical, psychological, social, financial, spiritual, residential) of the member to facilitate the members overall wellness and care. 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:

  • Assessment of members through the use of clinical and non-clinical tools and review of member specific health information/data; conducts comprehensive assessments of referred members needs/eligibility and in collaboration with the members care team determines an approach to resolving member issues and/or meeting needs by evaluating members benefit plan and available internal and external programs/services and resources.

  • Assessments will take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.

  • 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.

  • 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 and presents cases at case rounds for multidisciplinary focus to benefit members overall health and well-being.

  • Utilizes case management processes in compliance with regulatory and company policies and procedures.

  • Provides coaching, information and support to empower the member to make ongoing independent medical and/or health lifestyle choices.

  • Helps member actively and knowledgably participate with their provider in healthcare decision-making.

  • Adheres to care and quality management processes in compliance with regulatory and accreditation guidelines and company policies/procedures; and utilizes influencing/motivational interviewing skills to ensure maximum member engagement and to promote lifestyle/behavioral changes to achieve optimum level of health.

    BACKGROUND/EXPERIENCE desired:

    Registered Nurse (RN) is required

    3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

    DSNP experience is preferred

    Case management and discharge planning experience preferred

    Managed Care experience preferred

    Crisis intervention skills preferred

    Bilingual, Spanish speaking skills are highly desired.

    Medicare and duals experience and knowledge highly desired.

    EDUCATION

    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 (RN) is required

    FUNCTIONAL EXPERIENCES

    Functional - Clinical / Medical/Direct patient care (hospital, private practice)/3+ Years

    Functional - Medical Management/Medical Management - Case Management/3+ Years

    Functional - Medical Management/Medical Management - Direct patient care/3+Years

    TECHNOLOGY EXPERIENCES

    Technical - Desktop Tools/Microsoft Word/4+ Years/End User

    Technical - Desktop Tools/TE Microsoft Excel/4+ Years/End User

    Technical - Desktop Tools/Microsoft Outlook/4+ Years/End User

    Technical - Desktop Tools/Microsoft SharePoint/4+ Years/End User

    REQUIRED SKILLS

    Finance/Managing Aetnas Risk/FOUNDATION

    General Business/Applying Reasoned Judgment/ADVANCED

    Technology/Leveraging Technology/FOUNDATION

    DESIRED SKILLS

    General Business/Consulting for Solutions/ADVANCED

    Leadership/Collaborating for Results/ADVANCED

    Leadership/Fostering a Global Perspective/FOUNDATION

    Telework Specifications:

  • Full time telework; position can be worked anywhere in the US

  • Must be comfortable working 8AM-5PM ET

    ADDITIONAL JOB INFORMATION

    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