Case Manager – Select U.S. States at Aetna
Location: AR-Little Rock, CO-Denver, GA-Lawrenceville, MD-Linthicum, MO-St Louis, ND-Bismarck, PA-Blue Bell, RI-Providence, TX-Sugar Land
Type: Full Time
Potential for Telework: Yes
Full time telework opportunity for Candidates who must have a compact RN license and be located 2 hours from an Aetna office in one of the following states: AZ, AR, CO, DE, FL, GA, ID, IA, KY, MD, MS, MN, MO, NM, NE, NC, ND, RI, SC, SD, TN, TX, UT, VA, WV, WI. Candidates in PA who live close to the Blue Bell, PA office will also be considered but they must be in-office.
Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. 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: 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, assesses 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 interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
- 5+ years adult med-surg clinical practice experience required
- RN with current unrestricted state licensure required.
- Case Management in an integrated model preferred
- Bilingual preferred
Primary Location: PA-Blue Bell
Job Group: Healthcare
Percent Travel: 0 – 10%
Resource Group: 6
EEO Stmt: Aetna is an Equal Opportunity, Affirmative Action Employer
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