Aetna Case Manager in Denver, Colorado

Req ID: 37009BR

We are seeking individuals that will be a strong contributor to our CM team.

POSITION SUMMARY

The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individuals benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

Compact State or Arkansas RN license required.

Fundamental Components:

  • Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.

  • Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits

  • Using holistic approach consults with supervisors, Medical Directors and/or others 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 case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

    *Confident to navigate multiple systems, multiple platforms, and being comfortable in switching between technology platforms

    *Flexibility working in a rapidly changing environment as the program evolves and develops to meet our customers and members expectations

    *Manage multiple priorities and adapt in a fast paced environment. Being responsible for production and quality metrics

    Implement and coordinate care

    Interacting with the interdisciplinary care team to formulate a care plan for the member

    Educating patients, families, care givers, and members on conditions. Refer to resources (internal and external) available for the members to access additional support.

    Assisting and coordinating discharge planning

    Interpret applicable criteria and guidelines while assessing benefits to ensure appropriate administration of those benefits to help support in the development of the members care

    Adhere to all NCQA accreditation guidelines with timely documentation of the assessment and the care plan

    Demonstrate communication skills to engage and connect with members

    Collaborate with Medical Directors during Case Conferences to incorporate feedback

    BACKGROUND/EXPERIENCE desired:

    3-5 years clinical practice experience, Managed care industry experience preferred.

    Case Management experience required RN with current unrestricted state licensure.

    State or Arkansas required Case Management Certification "CCM" preferred

    Excellent verbal and written communication skills

    Proficiency in typing and use of computer applications

    EDUCATION

    The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

    LICENSES AND CERTIFICATIONS

    Nursing/Registered Nurse is required

    Nursing/Certified Case Manager (CCM) is desired

    FUNCTIONAL EXPERIENCES

    Functional - Nursing/Case Management/4-6 Years

    Functional - Nursing/Concurrent Review/discharge planning/4-6 Years

    TECHNOLOGY EXPERIENCES

    Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

    Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

    Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

    REQUIRED SKILLS

    Benefits Management/Understanding Clinical Impacts/FOUNDATION

    Leadership/Driving a Culture of Compliance/FOUNDATION

    Service/Providing Solutions to Constituent Needs/ADVANCED

    Telework Specifications:

    Work at home is an option for current staff currently working at home. If new employee to the company must be office based.

    ADDITIONAL JOB INFORMATION

    Strong case management skills needed to support new client programs

    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.

Job Function: Health Care