Registered Nurse experience in field of case management with history in the field of managed care, or insurance preferred in addition to 5 years clinical background as an RN. Prefer candidates have a specialty background of Oncology or Transplant as well as CCM and/or other URAC recognized certification. This position consists of working intensely as a case manager telephonically with patients and their care team for fully and/or self-funded clients.
This is a work-at-home/telework/telecommute Case Manager position that require 2 weeks of on-site training in the New Albany, Ohio office upon hire.
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.
Identifies and escalates quality of care issues through established channels.
Ability to speak to medical and behavioral health professionals to influence appropriate member care.
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. Incorporate the use of motivational interviewing with patients.
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.
Utilizes negotiation skills to secure appropriate options and services necessary.
Qualification Requirements & Preferences:
Minimum of 5 years clinical practice experience, as an RN e.g., hospital setting, alternative care setting such as home health or previous Case Management experience required.
Need to actively reach out and engage the patients.
Requires ability to document electronically using keyboard and computer screens - free form text.
Discharge planning experience preferred.
Managed Care experience preferred
The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Active, unrestricted Registered Nurse (RN) license is required.
Nursing/Certified Case Manager (CCM) is preferred.
Full-Time Telework (WAH)
Considered for any US location; 2 week training period in the New Albany, Ohio office is required
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
Benefits Management/Understanding Clinical Impacts/FOUNDATION
ADDITIONAL JOB INFORMATION
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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