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Aetna Care Manager in Philadelphia, Pennsylvania

Req ID: 62671BR

Job Description

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. Will also have requirement to see members face to face in the community.

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 masters degree; Required e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility

Crisis intervention skills; Required

Managed care/Medicaid experience; Preferred

Case management or discharge planning experience; Required

Minimum of a Master's degree in Behavioral/Mental Health or related field; Required

Unencumbered Behavioral Health license in the state where they work; Required

Licenses/Certifications:

Mental Health - Licensed Clinical Social Worker, Mental Health - Licensed Social Worker (LSW)

Functional Skills:

Clinical / Medical - Direct patient care (hospital, private practice), Clinical / Medical - Disease management, Medical Management - Medical Management - Case Management

Technology Experience:

Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Additional Job Information:

Must have physical health knowledge.

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this 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.

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