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in Richmond, VA

Pay
Estimated
$37 per hour
Hours
Full-time
About this job
  • 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.
  • 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 members 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

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