Aetna Clinical Care Manager in Toledo, Ohio

Req ID: 43762BR

POSITION SUMMARY

Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for members through assessment and member-centered care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources, optimal member functioning, and cost-effective outcomes.

Fundamental Components:

Assessment of Members:

-Through the use of clinical tools and review of member specific health information/data,

conducts comprehensive assessments of referred members needs/eligibility and, in collaboration with the members

care team, determines an approach to resolving member issues and/or meeting needs by evaluating the members

benefit plan and available internal and external programs/services and resources.

  • Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address

    complex clinical indicators which impact care planning and resolution of member issues.

  • Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical

    crisis and refers them to the appropriate clinical and service 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 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. Presents cases at case rounds/conferences to obtain a

    multidisciplinary perspective and recommendations 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.

    BACKGROUND/EXPERIENCE desired:

    RN licensure is required

    3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

    Strong organizational skills are required

    Must be familiar with Microsoft Excel and Outlook

    Strong written and verbal communication skills are required

    Well developed phone etiquette is required

    Case management experience preferred

    Managed Care experience preferred

    Nursing Facility experience a plus

    EDUCATION

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

    LICENSES AND CERTIFICATIONS

    Nursing/Registered Nurse (RN) is required

    FUNCTIONAL EXPERIENCES

    Functional - Nursing/Case Management/4+ Years

    Functional - Medical Management//1+ Years

    TECHNOLOGY EXPERIENCES

    Technical - Desktop Tools/Microsoft Outlook

    Technical - Desktop Tools/Microsoft Word

    Technical - Desktop Tools/TE Microsoft Excel

    Telework Specifications:

    Full-Time Telework (WAH) after 2-3 months of in-office training

    ADDITIONAL JOB INFORMATION

    This job will give the employee an opportunity to work with one of our most vulnerable populations; to make a difference in their lives and the healthcare they receive. It is working with the members, their families, doctors and healthcare facilities to enrich the lives of the members and help them obtain the most out of their healthcare benefits. Certification in Case Management (CCM) preferred.

    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