Req ID: 66603BR
Aetna International is a leading provider of international expatriate private medical insurance and health management solutions. We have over 1000 staff and growing every day. Our customer base is over 123,000 members located worldwide; and we have more than 71,000 health care professionals and facilities worldwide in the offices in all the major regions of the world.
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 Requirements
Assessment of Members/Claimants through the use of 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 multi disciplinary 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.
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.
Proven clinical practice experience, e.g.,hospital setting, alternative care setting such as home health or ambulatory care.
Healthcare and/or managed care industry experience.
Essential communication skills in English
Education and Certification Requirements
Clinically trained with Degree or recognized designation in western Medicine / Nursing or other western medical disciplines.
Job Function: Health Care
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.