Aetna Case Manager (RN) Registered Nurse Barry, Berrien, Calhoun, Cass, St Joe, Van Buren, Branch, Kalamazoo in Grand Rapids, Michigan
Req ID: 54587BR
Position Summary/MissionNurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical and disability needs of the member to facilitate the member s overall wellness and appropriate and timely return to work. In doing this the NCM 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.
Territory: We cover 8 counties- Barry, Berrien, Calhoun, Cass, St Joe, Van Buren, Branch, Kalamazoo. Fundamental Components & Physical Requirements include 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.• Assessments will 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 will include the member s level of work capacity and related restrictions/limitations.• Application and interpretation of disability criteria and guidelines, applicable policies and procedures, regulatory standards and disability benefit plan to determine eligibility and integration with available internal/external programs.• Using 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.• Supports, integrates and executes the IHD process.• Utilizes assessment techniques to assess for integration opportunities and determining work capacity.• Utilizes l interviewing skills to ensure maximum member engagement in disability process and a timely RTW. Exhibits the following Case Manager Behaviors
2-5 years clinical RN practice experience disease management
Discharge planning experience preferred
2 years experience in behavioral health, social services or appropriate related field equivalent to program focus
Disability case management experience preferred
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 is required active and unrestricted
Functional - Clinical / Medical/Concurrent review / discharge planning/
Functional - Medical Management/Medical Management - Case Management/
Functional - Clinical / Medical/Disease management/
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Benefits Management/Understanding Clinical Impacts/FOUNDATION
General Business/Applying Reasoned Judgment/ADVANCED
ADDITIONAL JOB INFORMATION
Helping your community to live healthy self directed lives.
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.
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Job Function: Health Care
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.