This is a Field position based in Sarasota, FL!

Position Summary

This role is performed face-to-face/field-based and requires those in the position to travel at least 25% of the time outside of the home/office to various facilities (such as acute care facilities, nursing homes, rehab centers, etc.), or community meetings on a defined schedule, adhering to the defined metrics, as required by the business. Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies.

Responsibilities

•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.

•This role is performed face-to-face/field-based and requires those in the position to travel at least 25% of the time outside of the home/office (e.g. acute care facilities, nursing home, other facility).

•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.

Required Qualifications:

•  Minimum 3+ years clinical practical experience

•  Minimum 2+ years CM, discharge planning and/or home health care coordination experience

•  Active and unrestricted Compact RN in FL

•  Willing to travel 25% within Sarasota, FL

Preferred Qualifications

•  Excellent analytical and problem-solving skills 

•  Effective communications, organizational, and interpersonal skills. 

•  Ability to work independently (may require working from home). 

•  Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications. 

•  Efficient and Effective computer skills including navigating multiple systems and keyboarding 

Willing and able to obtain multi state RN licenses if needed, company will provide.

•  Bilingual preferred - Spanish

• Certified Case Manager is preferred. 

• Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) is preferred, but not required 

Education

• Associate's degree or Nursing Diploma required

• Bachelor’s degree preferred