Aetna Care Manager - Medical RN in Elizabeth, New Jersey

Req ID: 54670BR

Position Summary:

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

Job Responsibilities:

  • Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel.

  • Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care. Interacts with members/clients telephonically or in person.

  • May be required to meet with members/clients in their homes, work-sites, or physicians office to provide ongoing case management services.

  • Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/clients appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits.

  • Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.

  • Prepares all required documentation of case work activities.

  • Interacts/consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.

  • May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.

  • Provides educational and prevention information for best medical outcomes.

  • Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources.

  • Testifies as required to substantiate any relevant case work or reports.

  • Conducts an evaluation of members/clients needs and benefit plan eligibility and facilitates integrative functions using clinical tools & information/data.

  • Utilizes case management processes in compliance with regulatory and company policies & procedures.

  • Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.

  • Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes & opportunities to enhance a members/clients overall wellness through integration.

  • Monitors member/client progress toward desired outcomes through assessment & evaluation.

    Background/ Experience Desired:

  • 5 years clinical practice experience

  • 2 years of Home Care/Hospice Care required

  • Ability to travel within a designated geographic area for in-person case management activities

  • Bilingual preferred

  • Knowledge of laws and regulations governing delivery of rehabilitation services.

  • Job-specific technical knowledge, (e.g., knowledge of workers compensation and disability industry for workers compensation case managers or case management).

  • Excellent analytical and problem solving skills

  • Effective communications, organizational, and interpersonal skills.

  • Ability to work independently (may require working from home).

  • Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.

  • Effective computer skills including navigating multiple systems and keyboarding.

    Education Required:

  • Bachelor degree in a closely-related field, or an equivalent combination of formal education and recent, related experience; preference will be given to applicants with a Masters degree.

    Licensures/Certifications:

  • Registered Nurse with active state license in good standing in the state where job duties are performed is required

  • Certified Case Manager is preferred.

  • Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) is preferred, but not required

    Telework Specifications:

    Interacts with members telephonically or in-person in the following locations: Passaic, Essex, Union, Hudson, Bergen

    Additional Job Information:

    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. 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.

    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.

    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

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.