Nurse Case Manager (NCM) is responsible for assessing members face-to-face and telephonically; and planning, implementing and coordinating all case management activities with members to evaluate the appropriate holistic needs (physical, psychological, social, financial, spiritual, residential) of the member to facilitate the members overall wellness and care. 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.
Routine field-based travel with personal vehicle is a job requirement. Qualified candidates must have dependable transportation, valid VA state drivers license and proof of vehicle insurance
Assessment of members through the use of clinical and non-clinical tools and review of member specific health information/data
Conducts comprehensive assessments of referred members needs/eligibility and in collaboration with the members care team determines an approach to resolving member issues and/or meeting needs by evaluating members benefit plan and available internal and external programs/services and resources; assessments will take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex clinical indicators which impact care planning and resolution of member issues
Using advanced clinical skills, performs crisis intervention with members experiencing behavioral health or medical crisis and refers them to the appropriate clinical and service providers for thorough assessment and treatment, as clinically indicated
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/service
Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or members needs to ensure appropriate administration of benefits
Using a holistic approach consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives and presents cases at case rounds for multidisciplinary focus to benefit members overall health and well-being
Utilizes case management processes in compliance with regulatory and company policies and procedures
Provides coaching, information and support to empower the member to make ongoing independent medical and/or health lifestyle choices
Helps member actively and knowledgably participate with their provider in healthcare decision-making
Adheres to care and quality management processes in compliance with regulatory and accreditation guidelines and company policies/procedures
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and to promote lifestyle/behavioral changes to achieve optimum level of health
3-5 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
Case management and discharge planning experience preferred
Managed Care experience preferred
Crisis intervention skills preferred
Bilingual, Spanish speaking skills are highly desired.
The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.
Nursing/Registered Nurse is required.
This is a telework position ideal individual must live near the Chantilly, VA area must be able to come into the Chantilly, VA office for 12 weeks of training.
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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.