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.
Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel. 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, work-sites, or physicians 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/clients appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits
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
Interacts/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
Communicates 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 & information/data
Utilizes case management processes in compliance with regulatory and company policies & 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 & opportunities to enhance a members/clients overall wellness through integration
Monitors member/client progress toward desired outcomes through assessment & evaluation
5 years clinical practice experience
2 years of Home Care/Hospice Care required
Ability to travel within a designated geographic area for in-person case management activities
Knowledge of laws and regulations governing delivery of rehabilitation services
Job-specific technical knowledge, (e.g., knowledge of workers compensation and disability industry for workers compensation case managers or case management)
Excellent analytical and problem solving skills
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
Registered Nurse with active state license in good standing in the state where job duties are performed is required Bachelor degree in a closely-related field, or an equivalent combination of formal education and recent, related experience; preference will be given to applicants with a Masters degree
Certified Case Manager is preferred
Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) is preferred, but not required
Interacts with members telephonically or in-person in the following locations: Tampa, Lee Sarasota
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. 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.
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.
Aetna takes our candidates'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.