Req ID: 60200BR Job Description Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. Fundamental Components included but are not limited to: This position is in office and telephonic in a fast paced, production environment. There may be some need for travel for face to face visits to members within the Tarrant County area The Clinical Case Manager will: -both outreach and receive calls from members -educate members on their disease processes -educate members on preventative care and wellness -collaborate care with providers -assist members with all of their needs. Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. Qualifications Requirements and Preferences: Case Management/ Discharge Planning in an integrated model preferred Bilingual preferred OB/Mother Baby/Labor Delivery experience ; Strongly Preferred 3+ years clinical practice experience; required RN with current unrestricted state licensure required. Licenses/Certifications: Nursing - Registered Nurse (RN) Functional Skills: Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Direct patient care (hospital, private practice), Nursing - Case Management, Nursing - Home Health Care Ambulatory Nursing, Nursing - Maternal and Infant care, Nursing - Medical-Surgical Care, Nursing - Neonatal Intensive Care, Nursing - OB/GYN, Nursing - Pediatrics Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel Required Skills: Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality Desired Skills: Benefits Management - Maximizing Healthcare Quality, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs Additional Job Information: Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. 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. Benefit Eligibility Benefit eligibility may vary by position. Click here to review the benefits associated with this position. 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.