Aetna Case Management Coordinator in Ridgewood, New Jersey

Req ID: 43758BR

POSITION SUMMARY

Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.

Fundamental Components:

Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred members needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating members benefit plan and available internal and external programs/services.

Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.

Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.

Enhancement of Medical Appropriateness and Quality of Care:

Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits

Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes

Identifies and escalates quality of care issues through established channels

Ability to speak to medical and behavioral health professionals to influence appropriate member care.

Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.

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. Monitoring, Evaluation and Documentation of Care:

In collaboration with the member and their care team develops and monitors established plans of care to meet the members goals

Utilizes case management and quality management processes in compliance.

BACKGROUND/EXPERIENCE desired:

2+ years of Care Management experience, preferably in the community.

Discharge planning experience preferred.

Managed care/utilization review experience preferred

Crisis intervention skills preferred.

New Jersey Choice Certification is a plus

EDUCATION

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

TECHNOLOGY EXPERIENCES

Technical - Desktop Tools/Microsoft Outlook

Technical - Multimedia

Technical - Operating Systems

REQUIRED SKILLS

Benefits Management/Encouraging Wellness and Prevention/ADVANCED

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Applying Reasoned Judgment/ADVANCED

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