A1A Case Manager RN

Job Description

Description:

This role is office based in High Point, NC.
Hours are Monday-Friday 8am-4:30pm with evening shift rotation until 8pm approximately once per week.

The Clinical Services Advocate is part of a dedicated team of clinical and service professionals empowered to take care of all aspects of a members health. Clinical Services Advocates are responsible for providing personalized, end to end member support including coordination of health care services, decision support, benefits support, complex case management and chronic condition management. Clinical Service Advocates serve as a single point of contact to help the provider, member and family maximize benefits and easily navigate the health care system. The Clinical Advocate provides the member and provider community with a powerful and proactive experience through high touch, personalized communications designed to help the member achieve their health ambition in collaboration with the provider

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Fundamental Components: -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. Background Experience: -RN with current, unrestricted licensure in state in which work is being done required
-Willingness to obtain RN licensure in other states as needed required
-3+ years of clinical experience is required
-Experience in case management, precertification, and/or discharge planning preferred
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. Required Skills: Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Understanding Clinical Impacts Desired Skills: Benefits Management - Maximizing Healthcare Quality, Benefits Management - Promoting Health Information Technology, Benefits Management - Supporting Medical Practice Functional Skills: Clinical / Medical - Direct patient care (hospital, private practice), Nursing - Case Management, Nursing - Discharge Planning Technology Experience: Aetna Application - Aetna Strategic Desktop Reporting, Aetna Application - Aetna Total clinical View, Desktop Tool - Microsoft Outlook Education: Nursing - Registered Nurse Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: 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.