Job Description
ABOUT OUR COMPANY
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.
POSITION SUMMARY
The Special Needs Case Manager (CM) utilizes clinical skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options and services to facilitate appropriate healthcare outcomes for members through communication and available resources to promote quality, cost-effective outcomes. The Case Management process includes: assessing the member's health status and care coordination needs, developing and implementing the Case Management plan, monitoring and evaluating the plan and involving the Medical Director as indicated and closing the case as appropriate when the member has met established criteria. The CM is responsible for the planning, development, implementation and timely oversight of case plans for members. Responsible for managing high-risk populations and the special needs case management process as defined by improving coordination, continuity, accessibility and appropriate utilization of health care services and community resources for high risk members.
ADDITIONAL JOB INFORMATION
Minimum of three years direct experience in Public Health, Home Health or Community Health providing services to clients within the home setting preferred.
Experience assisting members using community agencies strongly preferred. Two years managed care experience preferred.
3-5 years clinical practice experience, preferably in acute care, in a hospital setting.
2 years managed care case management and/or utilization management experience.
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Excellent/Proven clinical assessment skills with ability to make good decisions and exercise sound clinical and professional judgment as well as manage multiple priorities.
Preference given to candidates with experience working with special needs populations, e.g. members with disabilities, receiving home and community based waiver programs, technology dependent, etc.
This position will be based in Philadelphia, PA after training and orientation to take place in the Blue Bell, PA offices.
Job Requirements
LICENSES AND CERTIFICATIONS
Certified Case Manager is required
Registered Nurse (RN) is required
FUNCTIONAL WORK EXPERIENCES
Medical Management: Medical Management - Case Management
REQUIRED SKILLS
Apply clinical criteria and guidelines to ensure appropriate administration of benefits and optimum medical outcomes
Assess members clinical care needs
Authorize and coordinate required services in accordance with the benefit plan
Communicate to enhance effectiveness of medical management services (i.e. plan sponsors, claim administrators, physicians, members, family and health care team)
Consult with Medical Directors on cases that don t meet coverage policy bulletin or clinical criteria guidelines
Evaluate member progress in meeting case management plan goals
DESIRED SKILLS
Microsoft Excel
Microsoft Word
Present cases at Medical Director rounds and case conferences We value leadership, creativity and initiative. If you share those values and a commitment to excellence and innovation, consider a career with Aetna.
We conduct pre-employment drug and background testing.
Aetna does not permit the use of tobacco related products or drugs in the workplace. No agencies, please.
Aetna is an Equal Opportunity/Affirmative Action Employer. M/F/D/V
Aetna is committed to maintaining an environment in which all employees are treated equitably and given the opportunity within the context of the business to achieve their potential. Aetna's Affirmative Action responsibilities extend to women, minorities, persons with disabilities and veterans. Company policy also provides for equal opportunity for qualified individuals regardless of race, color, sex, national origin, religion, age, disability, veteran status, sexual orientation, gender identity or marital status.
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