Medical Case Manager

Aetna Global Benefits Limited
13 Feb 2018
16 Feb 2018
Contract Type
Full Time
Family Summary/Mission
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare in a cost effective manner to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.

Position Summary/Mission
The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)

• Assessment of Members/Claimants:
• Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.
• Enhancement of Medical Appropriateness & Quality of Care:
• -Application and/or interpretation of applicable criteria and 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 others to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.
• -Identifies and escalates quality of care issues through established channels.
• -Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs.
• Monitoring, Evaluation and Documentation of Care:
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
• Exhibits the following Case Manager Behaviors

Performance Measures

Background/Experience Desired

• Proven clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care.
• Healthcare and/or managed care industry experience.

Education and Certification Requirements

• Educated to degree level in a relevant discipline.
• Clinically trained with Degree or recognized designation in western Medicine / Nursing or other western medical disciplines.

Additional Information (situational competencies, skills, work location requirements, etc.)

• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
• Effective communication skills, both verbal and written.
• Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

•Arabic language

*Additional Information
Applications from job seekers who require sponsorship to work in the country of the applied position are welcome and will be considered alongside all other applications. However, those that require sponsorship may not be appointed to a post if a suitably qualified, experienced and skilled citizen of the country is available to take up the post, as the employing body is unlikely, in these circumstances, to satisfy local country immigration laws. For further information please visit the country’s immigration website

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