Aetna Medical Field Case Manager - Registered Nurse (RN) in Morrisville, North Carolina

Req ID: 40928BR

POSITION SUMMARY

The Medicare Medical Field Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individuals benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

This position focuses on the specialized case management needs of the Aetna Medicare Advantage population. Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Assessments will take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.

This position can be located in Morrisville, NC or Atlanta, GA.

Fundamental components include, but are not limited to:

  • Utilize clinical skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options and services to facilitate appropriate healthcare outcomes for members.

  • Collaborate to assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes.

  • Assess the member's health status and care coordination needs.

  • Develop and implement the Case Management plan. Reviews prior claims to address potential impact on current case management and eligibility.

  • Application and interpretation of medical criteria and guidelines, applicable policies and procedures, regulatory standards and benefit plan to determine eligibility and integration with available internal/external programs.

  • Using holistic approach assess the need for a referral to clinical resources for assistance in determining 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.

  • Utilizes Case Management processes in compliance with regulatory and company policies and procedures.

    Qualification Requirements:

  • Minimum 5 years of experience required.

  • Registered Nurse (RN) licensure required.

  • Technical proficiency required (Microsoft Office suite, ability to navigate multiple systems simultaneously.)

  • Ability to travel within a designated geographic area for in-person case management activities (10-25% local field travel) - must have valid license and reliable transportation.

  • Must be highly organized and able to manage continuously changing priorities.

  • Must be able to exercise independent and sound judgment in decision making.

    Preferred Skills:

  • Case Management experience preferred.

  • Certified Case Manager (CCM) preferred.

    Education

    The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.

    Licenses and Certifications

  • Registered Nurse (RN) is required

  • Certified Case Manager (CCM) is preferred

    FUNCTIONAL EXPERIENCES

    Functional - Nursing/Medical-Surgical Care/4-6 Years

    Functional - Nursing/Concurrent Review/discharge planning/1-3 Years

    Functional - Nursing/Case Management/1-3 Years

    TECHNOLOGY EXPERIENCES

    Technical - Operating Systems/Windows/1-3 Years/End User

    Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

    Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

    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.

    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.

Job Function: Health Care