Analyst, Case Management Specialist (Remote)

Program Overview:

Help us elevate our patient care to a whole new level! Join our Aetna t

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eam as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand DSNP to change lives in new markets across the country.

Position Summary/Mission:

The Case Management Coordinator utilizes critical thinking and judgment to collaborate and inform the case management process, The Case Management Coordinator facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and
education for members through the use of care management tools and resources.

Fundamental Components

Evaluation of Members: -Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member’s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available

internal and external programs/services.

Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate.
Coordinates and implements assigned care plan activities and monitors care plan progress.
Enhancement of Medical Appropriateness and Quality of Care: – Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.
Identifies and escalates quality of care issues through established channels.
Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs.
Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
Helps member actively and knowledgably participate with their provider in healthcare decision-making.
Monitoring, Evaluation and Documentation of Care: – Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications:

3+ years experience in health-related field

Preferred Qualifications:

CRC, CDMS, CRRN, COHN, or CCM certification
Medicare and Medicaid experience
Managed care experience
Experience working with geriatric special needs, behavioral health and disable population
Knowledge of assessment, screenings and care planning
Bilingual (English/Spanish; English/Creole)

Education:

Bachelor’s Degree or equivalent experience required

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