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Aetna is now a CVS Health Company

Onsite Clinical Case Manager

Primary Location: Atlanta, GA
Additional Locations: GA-Atlanta
Onsite: Children's Healthcare of Atlanta - 1600 Tullie Circle Atlanta GA 30329

Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. 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 overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies.

The Onsite Nurse Advocate at Children's Healthcare of Atlanta will:
  • Work with members to help understand their benefits and connect them to the appropriate resources available to them through a collaborative process of assessment, planning, facilitation, advocacy and communication.
  • Assist members in identifying modifiable risk factors and referring and leveraging the coaching resources provided by employer to coach on lifestyle change, including weight management, quitting tobacco, stress reduction, nutrition and increasing physical activity.
  • Assess, coach and referral of members with chronic health conditions to an Aetna In Touch Care Premier Nurse. Develop and implement goals with members to maintain optimum level of health.
  • Establish a plan of care based on member’s health status, and educational and support needs
  • Identify co-morbid conditions, hospitalizations, prescriptions, and other factors that could impact the coaching and support needs of the member outside the scope of the health coaching
  • Facilitate group coaching and health education sessions
  • Support clinical integration and collaboration on member’s care plan in conjunction with multiple health professionals
  • Refer members to appropriate resources and/or programs when indicated
  • Work with onsite health clinic to coordinate wellness activities as appropriate
  • Work with health plan clinical or customer service resources to coordinate benefits and available resources/programs
  • Work with the Children’s HR Benefits team, Aetna account management team and clinical program consultant to identify trends and gaps in the employee benefits plan through their interactions with employees.
  • The Nurse Advocate will be a conduit between clinical team, account team and Children’s
  • The Nurse Advocate will work with account to identify opportunities to include additional support needs, programs, service, and educational opportunities
  • In addition to providing face-to-face coaching, the Onsite Health Advocate seeks to engage employees at the designated location through:
    • Group coaching sessions
    • Telephone and email follow ups
    • Health education seminars using Aetna materials
    • Health awareness tables
    • Team meetings, meet-and-greet sessions
    • Health education newsletters
    • Other onsite events coordinated by the employer group
    • Very high level of customer service

Fundamental Components:
Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member’s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

The Dedicated onsite Nurse Advocate for Children’s Healthcare of Atlanta will engage, educate, promote and influence members to enable decisions related to achieving and maintaining optimal health status. She/he will work with both members and the HR Benefits /Wellness teams on ways to deliver the best member experience and optimize the benefits offered through the employee benefits plan.

The onsite nurse advocate will:
  • Present clinical and benefit strategy recommendations to Children's Healthcare of Atlanta based on the analysis of the Children's Healthcare of Atlanta specific utilization.
  • This analysis should include an overview of additional clinical management opportunities as well as an assessment of the effectiveness of the management programs currently in place, trends, new products, and service offerings to Children's Healthcare of Atlanta.
  • Review population health reporting and facilitate population health initiatives for this customer
  • Focus on wellness initiatives as indicated by the customer

Background Experience:
Case Management in an integrated model preferred.
Experience in population health or reporting preferred.
3+ years clinical practice experience required
RN with current unrestricted state licensure required in the state of GA.
This position may require travel to all Children's Healthcare of Atlanta sites

Additional Job Information:
This position will be onsite at Children's Healthcare of Atlanta and will have productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work at times involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.

Required Skills:
Benefits Management - Interacting with Medical Professionals, Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts

Desired Skills:
General Business - Communicating for Impact, Leadership - Collaborating for Results, Service - Providing Solutions to Constituent Needs

Functional Skills:
Nursing - Case Management, Nursing - Discharge Planning, Nursing - Disease management, Nursing - Medical-Surgical Care

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Nursing - Certified Case Manager (CCM), Nursing - Registered Nurse

Potential Telework Position:

Percent of Travel Required:
10 - 25%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

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

Candidate Privacy Information:
Aetna takes our candidate'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.

Click To Review Our Benefits (PDF)


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