Aetna Case Management Coordinator in Phoenix, Arizona
Req ID: 64031BR
This role is office based in Phoenix, AZ with 25--50% of travel required around Maricopa County, AZ.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for members by proving care coordination, support and education for members through the use of care management tools and resources.
Fundamental Components included but are not limited to:
Evaluation of Members;
-Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member s benefit plan and available internal and external programs/services.
-Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referrals.
-Coordinates and implements assigned care plan activities and monitors care plan progress.
Enhancement of Medical Appropriateness and Quality of Care;
-Uses a holistic approach to overcome barriers to meet goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.
- Identifies and escalates quality of care issues through established channels.
-Utilizes negotiation skills to secure appropriate options and services necessary to meet the member s benefits and/or healthcare needs.
- Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote 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 knowledgeably participate with their provider in healthcare decision-making.
Monitoring, Evaluation, and Documentation of Care;
- Utilizes case management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Qualifications Requirements and Preferences:
-A minimum of 2 years' Case management experience working with people who have been designated as having a serious mental illness (SMI) and working with people who are elderly or have a physical disability is required
-A minimum of a Bachelor's Degree is required
-Critical areas to succeed- organization, collaboration and time management.
Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance
Additional Job Information:
Authorizes comprehensive home and community cased and institutional healthcare services to facilitate delivery of appropriate quality healthcare, promote cost effective outcome and improved program/operational efficiency involving clinical issue. Exercise independent decision making regarding member safety. Case management for long term care members who reside in Maricopa County. Case Managers travel to members' homes and places of residence and complete assessments to ensure member safety, medical needs are met and services are provided
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.