Program Overview

Join Aetna in advancing patient-centered care at the highest level. As an industry leader in serving dual-eligible populations, we leverage best-in-class operational and clinical models to support individuals enrolled in both Medicare and Medicaid.

In this role, you will have a meaningful impact on members with complex medical and social needs. Through compassionate engagement and effective communication, we partner with members, providers, and community organizations to address the full spectrum of healthcare needs, including social determinants of health.

This is an exciting opportunity to contribute to transformative care delivery as we expand into new markets nationwide.

Family Summary / Mission

This role supports the delivery of appropriate benefits and healthcare services while determining member eligibility and promoting overall wellness. Responsibilities include developing, implementing, and supporting health strategies, policies, and programs that ensure effective benefit delivery and encourage successful, timely return-to-work outcomes.

Key focus areas include network management, clinical coverage, and policy development to enhance member health and well-being.

Position Summary / Mission

Case Managers employ a collaborative, member-centered approach that includes assessment, planning, facilitation, care coordination, evaluation, and advocacy.

The goal is to address the comprehensive health needs of members and their families by utilizing communication, clinical expertise, and available resources to drive high-quality, cost-effective outcomes.

Core Responsibilities

Member Assessment

• Conduct comprehensive assessments using clinical tools and data analysis to evaluate member needs and eligibility.
• Develop appropriate case strategies based on benefit plans and available internal and external resources.
• Apply clinical judgment to identify and address complex risk factors and care needs.
• Perform crisis intervention for members experiencing medical or behavioral health emergencies and ensure appropriate referrals and follow-up care.

Enhancing Care Quality and Appropriateness

• Apply and interpret clinical guidelines, case management protocols, policies, and regulatory standards.
• Collaborate with supervisors, Medical Directors, and interdisciplinary teams to address barriers and optimize outcomes.
• Present cases in multidisciplinary conferences to support informed decision-making.
• Identify and escalate quality-of-care concerns through established processes.
• Engage with medical and behavioral health professionals to promote appropriate care delivery.
• Utilize motivational interviewing and influencing skills to drive member engagement and encourage healthy lifestyle changes.
• Provide education, coaching, and support to empower members in managing their health and making informed decisions.
• Analyze utilization data, self-reports, and clinical information to identify comprehensive member needs.

Care Monitoring, Evaluation, and Documentation

• Partner with members and care teams to develop and monitor individualized care plans.
• Ensure compliance with case management standards, regulatory requirements, and organizational policies.
• Maintain accurate and timely documentation of member interactions and care activities.

• 3–5 years of post-master’s direct clinical experience (e.g., hospital, ambulatory, or outpatient settings).
• Case management and discharge planning experience preferred.
• Managed care or utilization review experience preferred.
• Crisis intervention experience preferred.
• Ability to work independently in a remote environment while effectively collaborating virtually.
• Willingness to travel within a designated geographic area as needed.
• Strong analytical, problem-solving, and organizational skills.
• Excellent communication and interpersonal abilities.
• Proficiency with Microsoft Office applications (Word, Excel, Outlook, PowerPoint) and other systems.
• Strong technical skills, including navigating multiple systems and efficient keyboarding.

• Active, unencumbered Behavioral Health clinical license (LCSW or LCPC) in the state of employment.
• Master’s degree in Behavioral Health, Mental Health or a related field