Aetna Case Manager in Gold River, California
Req ID: 46189BR
Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the transplant member's needs and to facilitate the members overall wellbeing. 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 members overall wellness . Services strategies policies and programs are comprised of network management and clinical coverage policies.
Fundamental Components, include but are not limited to:
-80% of activities focused on Transplant Case Management
-Interacts with the Provider and Member to achieve optimal outcomes within the benefit plan
-Collaborates with the NME Medical Director for benefit plan guidance and medical determinations
-Manages all aspects of the Transplant members care including non-transplant related services to include Utilization Management
-Works with the claims examiner to administer accurate payment per the benefit plan
-Involves Network for LOAs and contracting negotiations/needs
-RN with unrestricted, active license in the state of California; required
-Case Management experience; preferred
-Transplant and /or critical care experience; preferred
-Certified in Case Management; preferred
-Computer literate, skilled with Excel, Word and research utilizing the internet; required
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
Nursing/Certified Case Manager is desired
Functional - Nursing/Case Management/1-3 Years
Functional - Nursing/Concurrent Review/discharge planning/1-3 Years
Functional - Nursing/Critical Care/1-3 Years
Benefits Management/Understanding Clinical Impacts/FOUNDATION
General Business/Consulting for Solutions/ADVANCED
Leadership/Collaborating for Results/ADVANCED
Benefits Management/Maximizing Healthcare Quality/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
Position has potential to be office based if the person hired lives within commuting distance of an Aetna office and that office has space to accommodate the new hire. Candidate must live in California.
ADDITIONAL JOB INFORMATION
-Exciting opportunity to assist members during a complex and challenging time
-High level of job satisfaction in assisting members with resources, education and options for their medical care
-Being part of a cohesive and caring team
-Excellent resources within the NME team to trouble shoot and problem solve unique situations
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.
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