Case Manager Nurse (RN) – Service Coordinator 1 – Texas Star Kids (Pediatrics)


Full Time
Dallas, TX
Posted 1 week ago

At Aetna Better Health of Texas, we are committed to helping people on their
path to better health. By taking a total and connected approach to health, we
guide and support our members so they can get more out of life, every day. We
are 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 Texas STAR Kids members. We value diversity and are dedicated to
helping you achieve your career goals.

The Service Coordinator 1, (Case Manager RN) is a field-based position
responsible for face to face assessing, planning, implementing and
coordinating all case management activities with members to evaluate the
medical needs of the member to facilitate the member’s overall wellness.
Candidates may reside in any of these or adjacent counties: Collin, Dallas,
Ellis, Hurt, Kaufman, Navarro, and Rockwall. Develops a proactive course of
action to address issues presented to enhance the short and long-term outcomes
as well as opportunities to enhance a member’s overall wellness through
integration. Services strategies policies and programs are comprised of
network management and clinical coverage policies. This position requires
routine travel in the Dallas service area, 80-90% of the time. Some travel to
the Dallas office, support location, may also be required. Use of personal
vehicle when traveling in the field; must have active and valid TX driver’s
license, reliable transportation and vehicle insurance. Business mileage is
eligible for reimbursement, in accordance with travel policy guidelines. 71034
Fundamental Components:
Assessment of Members:

* Through the use of clinical tools and information/data review, conducts comprehensive face to face assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan/s and available internal and external programs/services.
* Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
* Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
* Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
* Actively engage with providers and member during key transitions of care.

Enhancement of Medical Appropriateness and Quality of Care:

* Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
* Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
* Identifies and escalates quality of care issues through established channels
* Ability to speak to medical and behavioral health professionals to influence appropriate member care.
* Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health
* Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
* Helps member actively and knowledgeably participate with their provider in healthcare decision-making
* Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs and co-morbid conditions.
* Reviews prior claims to address potential impact on current case management and eligibility. Assessment includes the member’s level of work capacity and related restrictions/limitations.

Monitoring, Evaluation and Documentation of Care:

* In collaboration with the member and their care team develops and monitors established person-centered plans of care to meet the member’s goals
* Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Background Experience:

* Minimum of 1 year previous service coordination or case management experience and experience with pediatric clients is required; integrated model experience is preferred
* Bilingual preferred (Spanish)
* 3+ years clinical practice experience RN with current unrestricted state licensure required
* RUG certified RN; or ability to complete RUG certification within 60 days of start date is required
* 2+ years health plan experience is preferred
* Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel. Strong keyboard and mouse skills required.
* Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
* Effective communication skills, verbal and written.

Additional Job Information:
Typical office working environment with productivity and quality
expectationsWork requires the ability to perform close inspection of hand
written and computer generated documents as well as a PC monitor.Sedentary
work involving periods of sitting, talking, listening. Work requires sitting
for extended periods, talking on the telephone and typing on the
computer.Ability to multitask, prioritize and effectively adapt to a fast
paced changing environmentPosition requires proficiency with computer skills
which includes navigating multiple systems and keyboardingEffective
communication skills, both verbal and written.

Clinical Licensure:
Registered Nurse

Potential Telework Position:

Percent of Travel Required:
75 – 100%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position.

Candidate Privacy Information:
Aetna takes our candidate’s data privacy seriously. At no time will any Aetna
recruiter or employee request any financial or personal information (Social
Security Number, Credit card information for direct deposit, etc.) from you
via e-mail. Any requests for information will be discussed prior and will be
conducted through a secure website provided by the recruiter. Should you be
asked for such information, please notify us immediately.

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