Aetna Care Management Associate in Baton Rouge, Louisiana
Req ID: 51546BR
Support comprehensive coordination of medical services for members utilizing the emergency room, including Care Team intake, screening and supporting the implementation of care plans to promote effective utilization of healthcare services. Promotes/supports quality effectiveness of Healthcare Services.
Responsible for initial review and triage of Care Team tasks. (*)
Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools. (*)
Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan. (*)
Monitors non-targeted cases for entry of appropriate discharge date and disposition. (*)
Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff. (*)
Identifies triggers for referral into Aetna's Case Management, Disease Management, Mixed Services, and other Specialty Programs. (*)
Utilizes eTUMS and other Aetna systems to build, research and enter member information, as needed. (*)
Support the Development and Implementation of Care Plans.
Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services
Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g.,health care providers, and health care team members respectively) (*)
Performs non-medical research pertinent to the establishment, maintenance and closure of open cases (*)
Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems. (*)
Adheres to Compliance with PM Policies and Regulatory Standards.
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. (*)
Protects the confidentiality of member information and adheres to company policies regarding confidentiality. (*)
May assist in the research and resolution of claims payment issues.
Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures. (*)
2-4 years experience as a medical assistant, office assistant.
1-2 years experience in MHR services.
Experience with field visits to members and providers.
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Functional - Medical Management/Medical Management - Case Management/1-3 Years
General Business/Communicating for Impact/ADVANCED
Leadership/Driving a Culture of Compliance/ADVANCED
General Business/Maximizing Work Practices/ADVANCED
Benefits Management/Encouraging Wellness and Prevention/ADVANCED
Benefits Management/Maximizing Healthcare Quality/ADVANCED
Benefits Management/Promoting Health Information Technology/ADVANCED
ADDITIONAL JOB INFORMATION
These positions are working within a high performing and fast paced team. The candidates should be able to work independently at times, but also take direction from leadership to best meet the needs of ABHLA members. These positions will have a focus of ER Diversion and reduction.
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