Complex Case Mgr position at Aetna in Pittsburgh

Aetna is at the momment seeking for Complex Case Mgr on Sat, 07 Dec 2013 18:21:23 GMT. on these cases. May work with worker’s compensation defense and plaintiff attorneys and testify as required. - May be responsible for comprehensive management...

Complex Case Mgr

Location: Pittsburgh Pennsylvania

Description: Aetna is at the momment seeking for Complex Case Mgr right now, this position will be placed in Pennsylvania. For detail informations about this position opportunity kindly see the descriptions. Req ID: 14841BR
Description - Internal
GENERAL SUMMARY
Functions as the central coordinator of care for members/injured employees identified as having chronic disease
processes or for members/injured employees in select physician practices. Responsible for implementing and
coordinating all case management activities relating to catastrophic cases and chronically ill members/injured employees
across the continuum of care including consultant referrals, home care visits, use of community resources, and alternative
levels of care. May be responsible for developing ! and executing implementation plans with a physician practice t! o
coordinate all case management activities. Uses computer-based systems to review medical experience of members/
injured employees and interact with staff. This position may specialize within a disease area.
ESSENTIAL RESPONSIBILITIES

• Responsible for the comprehensive management of members/injured employees with a catastrophic illness or for

members/injured employees in select physician practices.

• Responsible for the proactive management of chronically ill members/injured employees with the objective of

improving quality outcomes and decreasing costs.

• Responsible for the early identification and assessment of members/injured employees for admittance to a

comprehensive case management program.

• Applies case management concepts, principles, and strategies in the development of an individualized case plan that

addresses the member’s/injured employee’s broad spectrum ! of needs. The case planning process includes the following
actions: assessment, goal setting, establishing interventions related to goals, monitoring success of the interventions,
evaluating the success of the overall case plan, and reporting outcomes.

• Interviews members telephonically, in their home, physician office or in other facilities to provide initial and ongoing

case management services.

• Conducts regular discussions and updates with the member’s primary care physicians, other providers including

behavioral health providers, health plan Medical Directors, health services staff, or the injured employee’s insurance
company and employer regarding the status of a particular member/injured employee.

• Serves as the member/injured employee’s advocate to ensure they receive all necessary care allowed under their

benefit plan. Develops knowledge of community resources and alternat! e funding arrangements available to the member/
injured employee wh! en services are not available under their benefits program.

• Develops new programs as appropriate to reduce admissions for acute and chronic members/injured employees and

assist with decreasing their lengths of stay.

• Develops relationships with hospital social workers and community resources to assure appropriate management of

catastrophic and chronically ill members/injured employees.

• Develops an understanding of healthcare reimbursement methods that promotes the provision of cost effective

healthcare and the preservation of the member/injured employee benefits.

• Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these

issues are reported to the Quality Improvement Department.

• May serve as a consultant to the physician network(s) to insure overall improvement in quality of medical care and

outcomes.!

• May serve as liaison and key resource for Appeals Coordinators for cases involving utilization management, case

management, and general medical issues.

• May be responsible for handling sensitive appeal cases that involve complex medical issues assuring all regulatory

requirements are met. Works closely with senior management and the Legal Department on these cases. May work with
worker’s compensation defense and plaintiff attorneys and testify as required.

• May be responsible for comprehensive management of appeal cases for members/injured employees involving

transplants.

• Maintains confidentiality of member’s/injured employee’s information in accordance with HIPAA regulations.
• Performs other duties as required.

Qualifications - Internal
JOB SPECIFICATIONS

• Registered nurse with active state license.
• Bachelor’s degree or equivalent expe! rience preferred.
• Complies with all state certification requir! ements in the state where job duties are performed.
• Previous experience (usually 1+ year) in case management.
• Significant experience (usually 3+ years) clinical experience.
• If required by URAC/NCQA accreditation, or the health plan, case management certification must be obtained within 4

years of date of hire.

• Utilization management experience and knowledge of community resources preferred.
• Experience with using computer systems as part of the clinical activity.
• Regular local travel may be required.

Job Function: Health Care
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to Aetna.

If you interested on this position just click on the Apply button, you will be redirected to the official website

This position starts available on: Sat, 07 Dec 2013 18:21:23 GMT

Apply Complex Case Mgr Here