At Aetna Better Health of Texas, we are committed to helping people on their path to better health. By taking a total and connected approach to health, we guide and support our members so they can get more out of life, every day. We are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of Texas STAR Kids members. We value diversity and are dedicated to helping you achieve your career goals.
The Service Coordinator 1, (Case Manager RN) is a field-based position responsible for face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. Candidates may reside in any of these or adjacent counties: Collin, Dallas, Ellis, Hurt, Kaufman, Navarro, and Rockwall. 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. This position requires routine travel in the Dallas service area, 80-90% of the time. Some travel to the Dallas office, support location, may also be required. Use of personal vehicle when traveling in the field; must have active and valid TX driver's license, reliable transportation and vehicle insurance. Business mileage is eligible for reimbursement, in accordance with travel policy guidelines.
Fundamental Components: Assessment of Members:
Through the use of clinical tools and information/data review, conducts comprehensive face to face assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan/s and available internal and external programs/services.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Actively engage with providers and member during key transitions of care.
Enhancement of Medical Appropriateness and Quality of Care:
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
Identifies and escalates quality of care issues through established channels
Ability to speak to medical and behavioral health professionals to influence appropriate member care.
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes 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 knowledgeably participate with their provider in healthcare decision-making
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs and co-morbid conditions.
Reviews prior claims to address potential impact on current case management and eligibility. Assessment includes the member's level of work capacity and related restrictions/limitations.
Monitoring, Evaluation and Documentation of Care:
In collaboration with the member and their care team develops and monitors established person-centered plans of care to meet the member’s goals
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Minimum of 1 year previous service coordination or case management experience and experience with pediatric clients is required; integrated model experience is preferred
Bilingual preferred (Spanish)
3+ years clinical practice experience RN with current unrestricted state licensure required
RUG certified RN; or ability to complete RUG certification within 60 days of start date is required
2+ years health plan experience is preferred
Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel. Strong keyboard and mouse skills required.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
Effective communication skills, verbal and written.
Additional Job Information: Typical office working environment with productivity and quality expectationsWork 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 environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.
Clinical Licensure: Registered Nurse
Potential Telework Position: Yes
Percent of Travel Required: 75 - 100%
EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer
Benefit Eligibility: Benefit eligibility may vary by position.
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