Aetna Remote Jobs – Care Management Representative

Job Description:

Aetna One Advocate is Aetna’s premier service and clinical offering for Aetna nation-wide and creates industry-leading solutions for our customers and members. The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services. The mission of this model is designed to meet each member at every aspect of their health care journey. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members’ needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. This is an exciting time to join Aetna a CVS Health company in our journey to change the way healthcare is delivered today. We are health care innovators.

Job Responsibilities:

• Utilizes ATV, ASD and other Aetna systems to build, research and enter member information, as needed
• Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan
• Protects confidentiality of member information and adheres to company policies regarding confidentiality.
• As appropriate, Proactive CMAs reach out to providers for additional detail on a member’s plan of care
• Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services
• Adheres to Compliance with PM Policies and Regulatory Standards
• May assist in the research and resolution of claims payment issues
• Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems
• Prepare for outreach by researching previous calls and actions, collaborating with clinical staff to ensure most impactful service delivery, and documenting in ATV system as appropriate
• Performs non-medical research pertinent to the establishment, maintenance and closure of open cases
• Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools
• Emphasizes to members that Proactive CMA will be their direct contact in assisting with care coordination (i.e. between providers, collaborating within A1A, etc.
• Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) 1 standards where applicable, while adhering to company policy and procedures
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements
• As needed, refers to case management:
• Educate and influence members on use of tools and resources available that align to their specific needs and will drive effective benefit utilization
• Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff
• Uses motivational interviewing skills that drive development and implementation of a member’s plan of car
• Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively)
• Identifies triggers for referral into Aetna’s Case Management, Disease Management, Mixed Services, and other Specialty Programs

Job Requirements:

• High School Diploma or GED
• College degree preferre

Job Details:

Company: Aetna

Vacancy Type:  Full Time

Job Location: Chandler, AZ, US

Application Deadline: N/A

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