Job Description

Job Group Summary:

The dedication of talented and caring health care professionals drives the delivery of high quality, cost effective products and services. They make it possible for members to get the right health care treatment for their needs - and for Aetna to keep its competitive edge.

Family Summary:

Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare in a cost-effective manner to establish competitive business advantage for Aetna. Health Services strategies, policies,and programs are comprised of utilization management, quality management,network management and clinical coverage and policies.

Position Summary:

The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

Fundamental Components & Physical Requirements:

Assessment of Members/Claimants: Using clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.

Enhancement of Medical Appropriateness & Quality of Care:

· Application and/or interpretation of applicable criteria and 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 others to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review 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.

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.

Background Experience Desired:

· Healthcare and/or managed care industry experience.

· Proven clinical practice experience, e.g.,hospital setting, alternative care setting such as home health or ambulatory care.

Education and Certification Requirements:

· Clinically Trained with Degree or recognized designation in western Medicine / Nursing orother western medical disciplines.

· Educated to degree level in a relevant discipline.

Additional information:

· 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 in English (must) & Mandarin (good to have)

Req#

60888BR

Job Group

Health Care