Case Manager RNPrimary Location: Charleston, West Virginia
Additional Locations: WV-Charleston Apply
Full time telework opportunity for candidates in the Charleston, WV area, preferable Boone, Kenaw, Putnam or Jackson counties. Up to 25% travel for face-to-face visits is involved.
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.
Assessment of Members:
-Through the use of clinical tools and review of member specific health
information/data, conducts comprehensive assessments of referred member’s
needs/eligibility and, in collaboration with the member’s care team, determines
an approach to resolving member issues and/or meeting needs by evaluating the
member’s benefit plan and available internal and external programs/services and
-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 member’s 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
- 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 member’s 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 member’s goals.
- Adheres to care
management and quality management processes in compliance with regulatory and accreditation
guidelines and company policies and procedures.
3+ years clinical practice experience required
RN license required
Managed Care and/or Behavioral Health experience preferred
Crisis intervention skills preferred
Proficient computer skills preferred.Additional Job Information: Typical office working environment with productivity and quality expectations.
Sedentary work 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.
Will be about 25 % Local travel required with face to face visits offered to highest intensity members enrolled. Education: Nursing - Registered Nurse (RN) Potential Telework Position: Yes 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.
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