Case Manager RNPrimary Location: Toledo, Ohio
Additional Locations: OH-Toledo 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.
Evaluation of Members:
-Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred members needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating members benefit plan and available internal and external programs/services. Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate.
- Coordinates and implements assigned care plan activities and monitors care plan progress.
Enhancement of Medical Appropriateness and Quality of Care:
- Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.
- Identifies and escalates quality of care issues through established channels.
-Utilizes negotiation skills to secure appropriate options and services necessary to meet the members benefits and/or healthcare needs.
- Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.
-Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
-Helps member actively and knowledgeably participate with their provider in healthcare decision-making.
Monitoring, Evaluation and Documentation of Care:
- Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Exhibits the following Case Management Coordinator Behaviors
The highest level of education for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse (RN) is required
Minimum of 90 days in orientation. After successfully completing all the competencies, will be able to transition to home office.
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.
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