Aetna Field Case Manager in Concord, California
Req ID: 65776BR
Candidates must be located in the state of CA.
The Case Manager uses a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual s and family s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.
Fundamental Components included but are not limited to:
Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)
• Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.
• Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.
• Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, work-sites, or physician s office to provide ongoing case management services. (*)
• Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. (*)
• Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. (*)
• Prepares all required documentation of case work activities as appropriate. (*)
• Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. (*)
• May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. (*)
• Provides educational and prevention information for best medical outcomes. (*)
• Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. (*)
• Testifies as required to substantiate any relevant case work or reports. (*)
• Conducts an evaluation of members/clients needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member s/client s overall wellness through integration.
• Monitors member/client progress toward desired outcomes through assessment and evaluation.
•Exhibits the following Employee Behaviors
Qualifications Requirements and Preferences:
RN licensure required
3+ years clinical experience required
1+ years case management, discharge planning, or home health experience required
Ability to travel within a designated geographic area for in-person case management activities required
CCM experience preferred
Managed care experience preferred
Excellent analytical and problem-solving skills
Effective communications, organizational, and interpersonal skills
Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications
Effective computer skills including navigating multiple systems and keyboarding
Associates degree with equivalent experience, applicant would be required to obtain a bachelor s degree within 3-5 years as part of role development, state licensing laws may apply
Nursing - Registered Nurse
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Healthcare
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.