Req ID: 66815BR
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. Looking for a flexible, experienced RN to work with a new program at a client site in Oklahoma City, OK. Training includes 2-weeks of on-site training in the New Albany, OH home office starting on the first day of employment.
Requires an RN with unrestricted active license in Oklahoma and 5 years' experience as an RN; that includes a clinical background; case management experience; and Managed Care or insurance experience. Prefer candidates with a strong background in one of the following: Medical-Surgical, Maternity, Behavioral Health, Chronic Kidney Disease, Oncology or Transplant as well as a CCM and/or other URAC recognized accreditation.
Fundamental Components included but are not limited to:
Enhancement of Medical Appropriateness and Quality of Care:
-Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits.
- 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.
- 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.
-Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
- Utilizes case management processes in compliance with regulatory and company policies and procedures.
- Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
-Identifies and escalates member's needs appropriately following set guidelines and protocols.
Qualifications Requirements and Preferences:
- Requires an active and unrestricted Oklahoma RN license.
- 5+ years clinical practice experience as an RN required (IE: hospital setting with discharge planning, alternate settings such as home health/hospice working with precerts/authorizations.)
- Must be able to actively reach out to members to collaborate/guide their care.
- Requires ability to document electronically using keyboard and multiple computer screens--free form text/good typing skills.
- Experience with MCG, NCCN, Lexicomp a plus.
- Discharge planning experience from/to and transferring to lower levels of care preferred.
Nursing - Certified Case Manager (CCM), Nursing - Registered Nurse
Nursing - Case Management, Nursing - Concurrent Review/discharge planning, Nursing - Discharge Planning, Nursing - Medical-Surgical Care
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
Additional Job Information:
Work onsite in office environment with productivity and quality expectations while keeping office private.
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.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
Effective communication skills, both verbal and written.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Healthcare
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.