Aetna Case Manager RN in Sunrise, Florida

Req ID: 52676BR

20% travel required in Miami Dade County


Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case

management activities with members to evaluate the medical and disability needs of the member to facilitate the

members overall wellness and appropriate and timely return to work. 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 through integration. Services strategies policies and programs are comprised of network

management and clinical coverage policies.

Fundamental Components:

Aetna Better Health of Florida's discharge planning process supports the corporate Readmission Reduction Program to ensure smooth care transitions, help prevent readmissions and provide a better experience to our members. A designated Transition of Care Case Manager will outreach hospital discharge planners and Concurrent Review Nurses to offer assistance and connect with members who have trigger diagnoses noted below as well as a skilled need upon discharge:

Chronic conditions: Asthma, CHF, Diabetes, COPD

Hepatitis, HIV/AIDS

Trauma- burns, MVAs, etc.

Respiratory failure

Sickle Cell Anemia/Crisis



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.

Assessments will 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 will include the members level of work capacity and related restrictions/limitations.

Application and interpretation of disability criteria and guidelines, applicable policies and procedures, regulatory

standards and disability benefit plan to determine eligibility and integration with available internal/external programs.

Using 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.

Supports, integrates and executes the IHD process.

Utilizes assessment techniques to assess for integration opportunities and determining work capacity.

Utilizes l interviewing skills to ensure maximum member engagement in disability process and a timely RTW.


3-5 years clinical practice experience (Case Management or Acute Care) - required

Leadership Skills

Case management experience preferred

Managed Care experience preferred

Discharge planning experience preferred

Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

Effective communication skills, both verbal and written.

Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

Sedentary work involving periods of sitting, talking, listening.

Work requires sitting for extended periods, talking on the telephone and typing on the computer.

Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

Typical office working environment with productivity and quality expectations


The minimum level of education desired for candidates in this position is a Associate's degree or equivalent experience.


Nursing/Board of Nursing (Any State) is required


Technical - Computer Operations//2+ Years/


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 hereto review the benefits associated with this position.

Aetna takes our candidates'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