Aetna Inc. Phoenix , AZ 85002
Posted 3 weeks ago
This is a remote work from home role anywhere in the US with virtual training.
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. 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 member's needs to ensure appropriate administration of benefits.
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.
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.
Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
Utilizes case management processes in compliance with regulatory and company policies and procedures.
Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
Identifies and escalates member's needs appropriately following set guidelines and protocols.
Need to actively reach out to members to collaborate/guide their care.
Perform medical necessity reviews
Will need to obtain a multi state license upon hire.
Monday - Friday 8:30-5:00pm
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
5+ years experience as a Registered Nurse with hospital experience; preferably in the specialty.
Must hold an active/unrestricted RN licensure in the state that you reside.
1+ year experience documenting electronically using keyboard and multiple computer screens--free form text/good typing skills.
1+ year current or previous experience in Oncology, Behavioral Health/Substance Abuse, Transplant, or medical surgical
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