Position Summary
 

- This position is fully remote, and employees can work from any state. 

- Normal Working Hours: Work hours 5 days a week 8:00 AM - 4:30 PM EST, with a rotating schedule of 9:30 AM - 6:00 PM and 10:30 AM - 7:00 PM EST 3-4 times per month.  1-2 Saturdays 8:00 AM - 4:30 PM EST each quarter.

The Care Management Associate (CMA) supports comprehensive coordination of medical services that include intake and outgoing calls for medical services. We work closely with both case management team and utilization management team. 

The Care Management Associate will review eligibility and benefits and open pre-certification cases and either approve or send to nursing staff for review. 

Additional responsibilities to include but mot limited to the following:

-Responsible for initial review and triage of Care Team tasks. 

-Identifies principal reason for admission, facility, and member product to correctly apply intervention assessment tools. 

-Screen patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan. 

-Monitors non-targeted cases for entry of appropriate discharge date and disposition. 

-Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff. 

-Identifies triggers for referral into Aetna’s Case Management, Disease Management, Mixed Services, and other Specialty Programs. 

-Utilizes Aetna systems to build, research and enter member information, as needed. 

-Support the Development and Implementation of Care Plans. 

-Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services 

-Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively) 

-Performs non-medical research pertinent to the establishment, maintenance, and closure of open cases 

-Provides support services to team members by answering telephone calls, taking messages, researching information, and assisting in solving problems. 

-Adheres to Compliance with PM Policies and Regulatory Standards. 

-Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. 

-Protects the confidentiality of member information and adheres to company policies regarding confidentiality. 

-May assist in the research and resolution of claims payment issues. 

-Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures. 

Required Qualifications

- Minimum of 6 months of customer service experience required. 

Preferred Qualifications

- Effective communication, telephonic and organization skills. 

- Familiarity with basic medical terminology and concepts used in care management. 

- Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification, and resolution of issues to promote positive outcomes for members. 

- Computer literacy to navigate through Internal/external computer systems, including Excel and Microsoft Word. 

Education:

High School Diploma or equivalent GED