Aetna Registered Nurse (RN) - Clinical Care Manager in Upper Montclair, New Jersey
Req ID: 42777BR
JOIN OUR GROWING AETNA BETTER HEALTH OF NEW JERSEY TEAM!
Please note that this position has the future potential for work-at-home/telework on a part-time basis with proven job performance and proficiency. This is not a guarantee as business needs may change over time.
Additionally, strong computer proficiency (including ability to utilize the full Microsoft Office suite of programs) is a critical, required component to success in this role.
The Clinical Care Manager will 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. You will provide health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. This role 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.
Please note you must live near one of these two areas:
Targeting Bergen, Hudson, Essex, and Upton Counties for one position and for second position targeting Camden, Atlantic, Cumberland.
This position will require 50-75% travel to member's homes and facilities.
Assessment of Members:
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 3-5 years clinical practice experience, e.g., hospital setting, home health or managed care. RN license required in NJ Case management and discharge planning experience preferred Managed Care experience preferred Crisis intervention skills preferred Assessment of MembersStrong computer skills! Microsoft office is neededMedicaid experience is a huge plus!EDUCATION
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
LICENSES AND CERTIFICATIONS
ADDITIONAL JOB INFORMATION
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