Aetna VA Medicaid Care Management Associate in Richmond, Virginia
Req ID: 46054BR
Our care management associates complete telephonic outreach assessments to our members, answer inbound calls from member to assist them with front-line problems, and create referrals for case management.
Responsible for initial review and triage of Care Team tasks. () Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools. () Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan. () Monitors non-targeted cases for entry of appropriate discharge date and disposition. () Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff. () Identifies triggers for referral into Aetna's Case Management, Disease Management, Mixed Services, and other Specialty Programs. () Utilizes Aetna systems to build, research and enter member information, as needed. () Support the Development and Implementation of Care Plans. Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g.,health care providers, and health care team members respectively) () Performs non-medical research pertinent to the establishment, maintenance and closure of open cases () Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems. () Adheres to Compliance with PM Policies and Regulatory Standards. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. () Protects the confidentiality of member information and adheres to company policies regarding confidentiality. () May assist in the research and resolution of claims payment issues. Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures.
1-3 years previous experience as a medical assistant, office assistant is REQUIRED. Candidate should be comfortable with medical terminology.
Previous call center experience is preferred.
Strong communication, organizational and prioritization skills.
Demonstrated proficiency with MS Office Suite applications(Word, Excel, Outlook, SharePoint).
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years
Functional - Communications/Member communications/1-3 Years
Functional - Communications/Provider communications/1-3 Years
Functional - Customer Service/Customer service - production environment/1-3 Years
Functional - Customer Service/Customer service - transaction based environment/1-3 Years
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User
Service/Handling Service Challenges/FOUNDATION
Service/Demonstrating Service Discipline/FOUNDATION
Benefits Management/Interacting with Medical Professionals/FOUNDATION
General Business/Communicating for Impact/ADVANCED
Leadership/Fostering a Global Perspective/FOUNDATION
ADDITIONAL JOB INFORMATION
Strong customer service skills to coordinate service delivery including attention to members and providers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members. Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word. Ability to effectively participate in a multi-disciplinary team including internal and external participants. Familiarity with basic medical terminology and concepts used in care management. Effective communication, telephonic and organization skills.
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