Case Manager RNPrimary Location: Charleston, West Virginia
Additional Locations: WV-Charleston Apply
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
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 member’s benefits and/or
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.
60782Fundamental 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 motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. Background Experience: Case Management in an integrated model; Preferred
Proficient computer skills; Preferred
3+ years clinical practice experience; Required
Acute Care, ICU, Med/Surg experience; Preferred
RN with current unrestricted state licensure; Required
Additional Job Information:
Opportunity to Work from home available after training.
10-25% Travel time required to meet with members
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.
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
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.
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