Primary Location: Chandler, AZ Additional Locations: AZ-Chandler Apply
Description: What is A1A?
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.
Fundamental Components: 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
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 Background Experience: 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
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.
Clinical Licensure: N/A Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by 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.
At Aetna, a CVS Health Company, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna, a CVS Health Company.