Aetna Clinical Care Manager in Downers Grove, Illinois
Req ID: 42034BR
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.
The Clinical Care Manager utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider ordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.
This will be an office based role with filed responsibilities of making home visits. There is a potential to work from home in the future, yet never guaranteed.
You will have an opportunity to impact members and have face to face interaction with them!
Assessment of Members:
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred
members needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating members
benefit plan and available internal and external programs/services.- Applies clinical judgment to the incorporation of
strategies designed to reduce risk factors and address complex clinical indicators.
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical
crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically
indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Enhancement of Medical Appropriateness and Quality of Care:
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to
meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve
Identifies and escalates quality of care issues through established channels
-Ability to speak to medical and behavioral health professionals to influence appropriate member care.
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/
behavior changes to achieve optimum level of health
-Provides coaching, information and support to empower the member to make ongoing independent medical and/or
healthy lifestyle choices.
-Helps member actively and knowledgably participate with their provider in healthcare decision-making 1
-Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify
comprehensive member needs.
Monitoring, Evaluation and Documentation of Care:
-In collaboration with the member and their care team develops and monitors established plans of care to meet the members goals
-Utilizes case management and quality management processes
At least 2-5 or more years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. (3 or more years is preferred.) Case management and discharge planning experience preferred Managed Care experience preferred Crisis intervention skills preferredIndependent clinical license required, LPC, LMSW or RNIf RN Behavioral Health is preferredStrong computer skills including MS Office, Excel, Word and OutlookStrong keyboarding skills and organization skills needed!
The highest level of education desired for candidates in this position is a Master's degree.
LICENSES AND CERTIFICATIONS
Mental Health/Licensed Clinical Social Worker is desired
Nursing/Registered Nurse is desired
Functional - Customer Service//
Functional - Medical Management//
Functional - Clinical / Medical//
Technical - Desktop Tools/Microsoft Explorer/1-3 Years/End User
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User
ADDITIONAL JOB INFORMATION
Autonomy with setting work schedule
Potential to work at home with proven productivity
Positive work culture and wellness benefits
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.
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.
Job Function: Health Care