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Aetna A1A Proactive Care Management Associate in Phoenix, Arizona

Req ID: 67531BR

Job Description

Aetna One Advocate is Aetna s premier service and clinical offering for Aetna nation-wide and creates industry-leading solutions for our customers and members. The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services. The mission of this model is designed to meet each member at every aspect of their health care journey. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. This is an exciting time to join Aetna a CVS Health company in our journey to change the way healthcare is delivered today. We are health care innovators.

  • Support comprehensive & proactive coordination of medical services through direct member outreach that drives partnership in developing holistic plans of care and leads to influencing a member s effective use of programs, tools, and resources. Promotes/supports quality effectiveness of Healthcare Services

Fundamental Components included but are not limited to:

  • Conducts proactive, targeted member outreach to drive utilization of healthcare services aligned to member-specific health ambitions

  • Prepare for outreach by researching previous calls and actions, collaborating with clinical staff to ensure most impactful service delivery, and documenting in ATV system as appropriate

  • Educate and influence members on use of tools and resources available that align to their specific needs and will drive effective benefit utilization

  • Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively)

  • Emphasizes to members that Proactive CMA will be their direct contact in assisting with care coordination (i.e. between providers, collaborating within A1A, etc.)

  • Uses motivational interviewing skills that drive development and implementation of a member s plan of care

  • As appropriate, Proactive CMAs reach out to providers for additional detail on a member s plan of care

  • Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools

  • Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan

  • As needed, refers to case management:

  • Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff

  • Identifies triggers for referral into Aetna s Case Management, Disease Management, Mixed Services, and other Specialty Programs

  • Utilizes ATV, ASD and other Aetna systems to build, research and enter member information, as needed

  • Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services

  • Performs non-medical research pertinent to the establishment, maintenance and closure of open cases

  • Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems

  • Adheres to Compliance with PM Policies and Regulatory Standards

  • Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements

  • Protects confidentiality of member information and adheres to company policies regarding confidentiality. May assist in the research and resolution of claims payment issues

  • Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) 1 standards where applicable, while adhering to company policy and procedures

Qualifications Requirements and Preferences:

  • 2-4 years experience as a medical assistant, office assistant

  • Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members

  • Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word

Functional Skills:

Administration / Operation - Data Entry, Clinical / Medical - Clinical claim review & coding, Clinical / Medical - Precertification

Technology Experience:

Aetna Application - Aetna Strategic Desktop Reporting, Aetna Application - Aetna Total clinical View

Required Skills:

General Business - Communicating for Impact, Service - Demonstrating Service Discipline, Service - Handling Service Challenges

Additional Job Information:

Effective communication, telephonic and organization skills.Familiarity with basic medical terminology and concepts used in care management.Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.Ability to effectively participate in a multi-disciplinary team including internal and external participants.

Benefit Eligibility

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.