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Req ID: 64890BRJob DescriptionSupport comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of care plans to promote effective utilization of healthcare services. Promotes/supports quality effectiveness of Healthcare Services. Supports a telephone queue for member welcome calls, as assigned.Fundamental Components included but are not limited to:
Responsible for initial review and triage of Care Team tasks.
Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools.
Screens 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 Project Management 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.
Supports a telephone queue for member welcome calls, as assigned.
Qualifications Requirements and Preferences:
2-4 years’ experience as a medical assistant, office assistant.
Familiarity with medical terminology. Managed care experience is preferred.
Familiarity with Medicaid is desired.
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Functional Skills:Administration / Operation - Data Entry, Administration / Operation - Document production & distribution, Administration / Operation - File Maintenance, Clinical / Medical - Direct patient care (hospital, private practice), Medical Management - Medical Management - Direct patient careTechnology Experience:Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft ExcelRequired Skills:Benefits Management - Interacting with Medical Professionals, Service - Creating a Differentiated Service Experience, Technology - Leveraging TechnologyDesired Skills:General Business - Communicating for Impact, General Business - Maximizing Work Practices, Leadership - Fostering a Global PerspectiveAdditional Job Information:
Exceptional 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.
Proficiency with personal computer is required. Demonstrated ability to navigate through internal/external computer applications/systems and use of keyboard and mouse. Proficient with MS Office suite applications, i.e., WORD, Excel, Outlook, and SharePoint.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.
Familiarity with basic medical terminology and concepts used in care management.
Effective communication, telephonic and organization skills.
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way. Benefit EligibilityBenefit eligibility may vary by position. Click here to review the benefits associated with this position.Job Function: HealthcareAetna 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.
