Aetna Veterans Jobs

Job Information

Aetna Case Manager RN in Fremont, California

Req ID: 64417BR

Job Description

Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member s overall wellness. 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 overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies.

Fundamental Components included but are not limited to:

Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Also performs Utilization Management for inpatient/SNF/Acute Rehab/NICU/Peds using MCG criteria.

Qualifications Requirements and Preferences:

Case Management in an integrated model preferred

Bilingual preferred

3+ years clinical practice experience

Utilization Management Review experience preferred

RN with current unrestricted state licensure required

Licenses/Certifications:

Nursing - Registered Nurse (RN)

Functional Skills:

Management - Management - Health Care Delivery, Medical Management - Medical Management - Hospital, Nursing - Case Management, Nursing - Concurrent Review/discharge planning

Technology Experience:

Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Required Skills:

Benefits Management - Maximizing Healthcare Quality, General Business - Demonstrating Business and Industry Acumen, Leadership - Driving a Culture of Compliance

Desired Skills:

Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment, General Business - Communicating for Impact

Additional Job Information:

Typical office working environment with productivity and quality expectationsWork requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.

Benefit Eligibility

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.

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