Aetna Clinical Case Manager Behavioral Health in Richmond, Virginia
Req ID: 55924BR
Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.
Standard business hours.
Fundamental Components but not limited to the following:
Assessment of Members:
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred members needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating members 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 members needs to ensure appropriate administration of benefits
Using a 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 a 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 the 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:
3+ years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
Case management and discharge planning experience preferred
Managed care/utilization review experience preferred
Crisis intervention skills preferred
The minimum level of education desired for candidates in this position is a Master's degree or equivalent experience.
LICENSES AND CERTIFICATIONS one of the following is required:
Mental Health/Licensed Independent Social Worker (LCSW)
Mental Health/Licensed Professional Counselor (LPC)
Nursing/Psychiatric and Mental Health Nurse (PMHNP)
Certified Case Management certification preferred (CCM)
Functional - Medical Management/Medical Management - Case Management/1-3 Years
Benefits Management/Encouraging Wellness and Prevention/ADVANCED
Benefits Management/Interacting with Medical Professionals/ADVANCED
Benefits Management/Understanding Clinical Impacts/ADVANCED
in-office training, with opportunity to transition to telework after demonstrated competency with job skills
ADDITIONAL JOB INFORMATION
Opportunity to work with nationally recognized company with room for growth
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 candidates'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
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.