This position will be working from home and will require the employee to be located in either GA, NC or FL
Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.
The Case Manager uses a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.
Aetna is an Equal Opportunity, Affirmative Action Employer
Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)
Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.
Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.
Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician's office to provide ongoing case management services. (*)
Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client's appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. (*)
Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. (*)
Prepares all required documentation of case work activities as appropriate. (*)
Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. (*)
May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. (*)
Provides educational and prevention information for best medical outcomes. (*)
Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. (*)
Testifies as required to substantiate any relevant case work or reports. (*)
Conducts an evaluation of members/clients' needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.
Utilizes case management processes in compliance with regulatory and company policies and procedures.
Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member's/client's overall wellness through integration.
Monitors member/client progress toward desired outcomes through assessment and evaluation.
3+ years clinical practical experience required
1+ years Case Management required
1+ year of Medicaid experience required
1+ years discharge planning and/or home health care coordination experience
Ability to travel within a designated geographic area for in-person case management activities as directed by Leadership and/or as business needs arise
Excellent analytical and problem-solving skills
Previous telework experience preferred
Effective communications, organizational, and interpersonal skills.
Ability to work independently (may require working from home).
Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.
Effective computer skills including navigating multiple systems and keyboarding
Education and Certification Requirements
Registered Nurse with active state license in good standing within the region where job duties are performed is required.
Associates degree with equivalent experience, applicant would be required to obtain a bachelor's degree within 3-5 years as part of role development, state licensing laws may apply
Certified Case Manager is preferred.
Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) is preferred
Benefit eligibility may vary by position.
Candidate Privacy Information
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.