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Aetna Field Case Manager in Philadelphia, Pennsylvania

Req ID: 64274BR

Job Description

Candidates must be located in the state of PA.

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:

Background/Experience:

-3-5+ years clinical practical experience

-2-3+ years CM, discharge planning and/or home health care coordination experience

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

-Bilingual preferred

-Excellent analytical and problem-solving skills

-Effective communications, organizational, and interpersonal skills.

-Ability to work independently (may require working from home).

-Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.

-Effective computer skills including navigating multiple systems and keyboarding

-Registered Nurse with active state license in good standing in the state where job duties are performed is required

-Associates degree with equivalent experience, applicant would be required to obtain a bachelor s degree within 3-5 years as part of role development, state licensing laws may apply

-Certified Case Manager is preferred

-Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) is preferred, but not required

Licenses/Certifications:

Nursing - Registered Nurse

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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