Support comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of care plans to promote effective utilization of healthcare services. Promotes/supports quality effectiveness of Healthcare Services.
Responsible for initial review and triage of Care Team tasks
Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools
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
Monitors non-targeted cases for entry of appropriate discharge date and disposition
Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff
Support the Development and Implementation of Care Plans
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
Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g.,health care providers, and health care team members respectively)
Performs non-medical research pertinent to the establishment, maintenance and closure of open cases
Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems
Adheres to Compliance with PM Policies and Regulatory Standards
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements
Protects the confidentiality of member information and adheres to company policies regarding confidentiality
May assist in the research and resolution of claims payment issues
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) standards where applicable, while adhering to company policy and procedures BACKGROUND/EXPERIENCE desired:
2-4 years experience as a medical assistant, office assistant, health care support EDUCATION
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience. ADDITIONAL JOB INFORMATION
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.
Familiarity with basic medical terminology and concepts used in care management.
Effective communication, telephonic and organization skills.
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
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