Aetna Case Manager in Denver, Colorado
Req ID: 37009BR
We are seeking individuals that will be a strong contributor to our CM team.
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.
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
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
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 - Nursing/Case Management/4-6 Years
Functional - Nursing/Concurrent Review/discharge planning/4-6 Years
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
Benefits Management/Understanding Clinical Impacts/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
Service/Providing Solutions to Constituent Needs/ADVANCED
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