This is an in-office position in the Cincinnati, OH office for candidates located in Butler or Hamilton county with 50-75% field travel for member visits.
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate physical, behavioral and/or social services for members through assessments and member-centered care planning. Then direct provider coordination/collaboration to promote effective utilization of available resources, to promote optimal member functioning, and cost-effective outcomes.
Assessment of Members:
Through the use of clinical tools and review of member specific health information/data, conducts comprehensive assessments of referred members needs/eligibility and, in collaboration with the members care team. Determines an approach to resolving member issues and/or meeting needs by evaluating the members benefit plan and available internal and external programs/services and resources.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex clinical indicators which impact care planning and resolution of member issues.
Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical crisis and refers them to the appropriate clinical and service providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Enhancement of Medical Appropriateness and Quality of Care:
Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits.
Using a holistic approach consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives. Presents cases at case rounds/conferences to obtain a multidisciplinary perspective and recommendations in order to achieve optimal outcomes.
Identifies and escalates quality of care issues through established channels
Ability to speak to medical and behavioral health professionals to influence appropriate member care.
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes 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 knowledgably participate with their provider in healthcare decision-making
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
Utilize clinical judgment.
RN License required
5+ years clinical practice experience required
strong computer skills required
home health/community nursing experience preferred
Case management and discharge planning experience preferred
Managed care/utilization review experience preferred
Crisis intervention skills preferred
The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
Nursing/Registered Nurse is required
90 days in office training
ADDITIONAL JOB INFORMATION
Meeting complex members needs and working in the community to increase their independence.
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.
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