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Case Manager

Primary Location: Shanghai, China
Additional Locations: CHN-Shanghai
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Family Summary/Mission

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

Position Summary/Mission

Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical and disability needs of the member to facilitate the member’s overall wellness and appropriate and timely return to work. In doing this the NCM 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.

Fundamental Components & Physical Requirements include but are not limited to (* denotes essential functions)

• 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.

• Assessments will 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 will include the member’s level of work capacity and related restrictions/limitations.

• Application and interpretation of disability criteria and guidelines, applicable policies and procedures, regulatory standards and disability benefit plan to determine eligibility and integration with available internal/external programs.

• Using 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.

• Supports, integrates and executes the IHD process.

• Utilizes assessment techniques to assess for integration opportunities and determining work capacity.

• Utilizes l interviewing skills to ensure maximum member engagement in disability process and a timely RTW.

• Oversee South East Region

• Exhibits the following Case Manager Behaviors

Background/Experience Desired

• 5 years clinical practice experience

• Registered nurse or doctor

• Have insurance experience, be able to understand the product, and serve insurance clients

• The knowledge of South East Asia’s medical system is necessary

• Bilingual preferred

• Disability case management experience preferred

Education and Certification Requirements

RN with current unrestricted state licensure required.

Additional Information (situational competencies, skills, work location requirements, etc.)

• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

• Effective communication skills, both verbal and written.

• Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

• Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.

• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

• Typical office working environment with productivity and quality expectations

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