Case Manager RN OR LCSW Greenbrier County, WVPrimary Location: Charleston, West Virginia
Additional Locations: WV-Charleston Apply
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Fundamental Components but not limited to the following:
Assessment of Members:
-Through the use of clinical tools and review of member specific health information/data, conducts comprehensive assessments of referred members needs/eligibility and, in collaboration with the members care team, determines an approach to resolving member issues and/or meeting needs by evaluating the members benefit plan and available internal and external programs/services and resources.
-Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical crisis and refers them to the appropriate clinical and service providers for thorough assessment and treatment, as clinically indicated.
Enhancement of Medical Appropriateness and Quality of Care:
- Application and/or interpretation of applicable criteria and clinical guidelines, standardized care 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 clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
- Ability to speak to medical and behavioral health professionals to influence appropriate member care. - Helps member actively and knowledgably participate with their provider in healthcare decision-making.
- Utilizes negotiation skills to secure appropriate options and services necessary to meet the members benefits and/or healthcare needs.
Monitoring, Evaluation and Documentation of Care:
- In collaboration with the member and their care team develops and monitors established plans of care to meet the members goals. - Adheres to care management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures. Nurse Case Manager is responsible for telephonically and in person face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical and behavioral needs of the member to facilitate the members overall wellness. In doing this the nurse CM 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 members overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies.
3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
OB experience strongly preferred
Case management and discharge planning experience preferred
Managed Care and/or Behavioral Health experience preferred
Crisis intervention skills preferred
Proficient computer skills preferred OB and/or BH experience preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience for RN.
The minimum level of education desired for candidates in this position is a Master's degree LCSW.
LICENSE AND/OR CERTIFICATIONS one of the following is required:
Nursing/Registered Nurse RN
Nursing/Licensed Social Worker (LCSW)
Remote Teleworker residing in Greenbrier County, WV.
ADDITIONAL JOB INFORMATION
Care Manager position with opportunity for Telework.
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.
Jobs for you
Recently Viewed Jobs
You do not have any recently viewed jobs
Your Saved Jobs
You do not have any saved jobs
Sign up for Job Alerts
Join our Talent Community
At Aetna, 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.
Join Our Talent Community
Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.