Case Manager RN - LTSS (Work at Home)

Work-from-home Case Manager RN on Aetna's Long-Term Services and Supports (LTSS) team. Review provider requests including DMAS documents, MD orders, provider justifications, internal assessments, InterRai, and NCQA notes. Develop proactive courses of action to enhance short- and long-term member outcomes and overall wellness through care integration. Use clinical tools and data review to evaluate member needs and benefit plan eligibility, and facilitate smooth transitions to Aetna programs. Apply clinical judgment to strategies that reduce risk factors and address complex health and social determinants impacting care planning. Assessments incorporate information from multiple sources to address co-morbid and multiple diagnoses affecting functionality. Review prior claims for impact on current case management. Refer to clinical resources as needed and consult with supervisors to overcome barriers. Present cases at multidisciplinary case conferences. Ensure compliance with regulatory and company policies. Requires active unrestricted Virginia or Compact RN license, 3 years of clinical experience (Med-Surg, Behavioral Health, Long-Term Care, or UR preferred), and 1+ year of managed care experience. Associate's degree required. Salary $60,522–$129,615 plus bonus eligibility.