Job Summary

The Care Manager Specialist is a member of the Care Team. The Care Manager Specialist is responsible for the care management of members that are enrolled in the Dual Special Needs Plan and have limited health conditions. These members are usually stratified as low risk. The Care Manager Specialist will work in conjunction with the Nurse Care Manager, Care Coordinator, Transition of Care (TOC) Coach, and other members of the Care Team to improve the member’s health outcomes, address social determinants of health and connect members with community based organizations. The Care Manager Specialist will assess member’s needs as well as gaps in care, communicate with the member’s Primary Care Provider (PCP), maintain updated individualized care plans and participate in Interdisciplinary team meetings. Care Managers will be able to identify members who’s needs require clinician involvement and transition members appropriately. 

Job Description

Conducts routine care coordination, support, and education through the use of care management resources in order to facilitate appropriate healthcare outcomes for members. Helps implement projects, programs, and processes for Case Management. Applies practical knowledge of Case Management to administer best of class policies, procedures, and plans for the area. Consults with Nurse Case Managers, Supervisors, Medical Directors and/or other members of the Care team using a holistic approach. Presents cases at case conferences to obtain a multidisciplinary review in order to achieve optimal outcomes. Identifies and escalates quality of care issues through established channels. Demonstrates negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs. Delivers influencing/ motivational interviewing skills to ensure maximum member engagement and promote 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. Assists in encouraging members to actively participate with their provider in healthcare decision-making. Conducts comprehensive evaluations of referred members’ needs/eligibility using care management tools and recommends an approach to case resolution. 

- This is a full-time telework position with less than 10% travel required.
- Hours for this position are Monday-Friday 8:00am - 5:00pm in time zone of residence.

Program Overview: 
Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand DSNP to change lives in new markets across the country.

Fundamental Components  

- Uses tools and information/data review to conduct an evaluation of member’s needs and benefits.
- Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness.
- Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate.
- Coordinates and implements assigned care plan activities and monitors care plan progress.
- Uses a holistic approach to consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order 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.
- Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote 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 knowledgably participate with their provider in healthcare decision-making.
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications

- 2 years experience in behavioral health or social services
Must have the ability to work 8:00a-5:00p local time
- 2 years of experience with Microsoft Office applications (Word, Excel, Outlook)

Preferred Qualifications

-Case management and discharge planning experience
-Managed Care experience  

- Non-licensed master level clinician with either degree being in behavioral health or human services preferred (psychology, social work, marriage and family therapy, counseling)

Education

Bachelor’s degree or equivalent work experience.