Care Management Associate

Care Management Associate

Requirements

• Must reside in Ohio.
• 2-4 years’ experience in healthcare field or working with foster, child and family welfare populations (e.g., experience in a medical office, hospital setting, case worker in community health setting).
• Effective communication, telephonic and organization skills with ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm.
• 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.
• 2+ years’ demonstrated proficiency with personal computers, keyboard and multi-system navigation, and MS Office Suite application (Teams, Outlook, Word, Excel, etc.).
• Some in-state travel (5-10%) may be required for meetings, community engagement and training. Must possess reliable transportation and be willing. Mileage is reimbursed per our company expense reimbursement policy.
• Must pass CANS certification exam (within the first 3 months of employment) for the purpose of administering CANS with child and family teams.

Responsibilities

• Responsible for initial review and triage of members.
• Manages population health member enrollment for child and family welfare.
• Manages a low tier member caseload.
• Development of wellness plans, providing community resources, reviewing gaps in care, administering health questionnaires, and other targeted child welfare goals applicable to population health.
• Completes outbound calls to identify and engage appropriate community resources.
• Screens members 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.
• 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.
• Supports the development and implementation of wellness 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, researching information, and assisting in solving problems.
• Adheres to compliance with 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.
• Manage population health member enrollment for child and family welfare. Development of Wellness Plan, providing community resources, reviewing gaps in care, administering health questionnaires, and other targeted child welfare goals applicable to population health.
• Effective communication, telephonic and organization skills with ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm.
• Demonstrates ability to meet daily metrics with speed, accuracy and a positive attitude.
• 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, adhering to care management processes (to include, but not limited to, privacy and confidentiality, quality management processes in compliance with regulatory, accreditation guidelines, company policies and procedures).
• Completes documentation of each member call in the electronic record, thoroughly completing required actions with a high level of detail to ensure compliance requirements are met with efficiency.
• Works independently and competently, meeting deliverables and deadlines while demonstrating an outgoing, enthusiastic and caring presence telephonically.
• Ability to effectively participate in a multi-disciplinary team including internal and external participants.
• Outreach and promoting active connection through management of persistent outreach.

Preferred Qualifications

• Motivational interviewing skills
• Call Center experience
• Managed Care experience