Case Manager Registered Nurse - LTSS - Work at Home

About the position This Case Management position is with Aetna’s Long-Term Services and Supports (LTSS) team and is a Work From Home. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone, and typing on the computer. Nurse Case Manager is responsible for reviewing provider requests, including DMAS documents, MD orders, provider justification for services and internal assessment, InterRai and NCQA notes. 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 member’s overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies. 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. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments 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. Using a 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.

Responsibilities

• Reviewing provider requests, including DMAS documents, MD orders, provider justification for services and internal assessment, InterRai and NCQA notes.
• Developing a proactive course of action to address issues presented to enhance the short and long- term outcomes as well as opportunities to enhance a member’s overall wellness through integration.
• Conducting an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• Applying clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.
• Assessing the need for a referral to clinical resources for assistance in determining functionality.
• Consulting with supervisor and others in overcoming barriers in meeting goals and objectives.
• Presenting cases at case conferences for multidisciplinary focus to benefit overall claim management.
• Utilizing case management processes in compliance with regulatory and company policies and procedures.

Requirements

• Registered Nurse with current unrestricted Virginia or Compact Licensure
• 3 years Clinical Experience (Preferably in Medical-Surgical Nursing, Behavioral Health, Long term Care, Utilization Review etc.)
• 1+ years Managed Care experience.
• Proficiency with computer skills which includes navigating multiple systems and keyboarding.

Nice-to-haves

• Effective communication skills, both verbal and written.
• Associates Degree

Benefits

• medical
• dental
• vision coverage
• paid time off
• retirement savings options
• wellness programs

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