Case Manager, Registered Nurse – Single Point of Contact

Job Description:

• Serve as a primary contact for members, guiding them through benefits and care options for a seamless experience
• Promote holistic well-being through initiatives focused on physical and mental health
• Proactively engage high-cost claimants and frequent ER users, educating on appropriate care settings and facilitating PCP connections
• Monitor out-of-network utilization and educate members on cost-effective, in-network care options
• Coach members with chronic conditions, set personalized health goals, and connect them to Aetna One Flex Nurse for ongoing support
• Act as client lead with case management teams, aligning care strategies with client culture and goals
• Ensure smooth Transition of Care for new members and refer to specialized programs (e.g., 2nd MD, Health Advocate, Lantern, EAP)
• Leverage data analytics to identify gaps in care and design targeted outreach strategies to close those gaps
• Review appeals and denials to identify policy improvement opportunities that remove barriers to care
• Analyze utilization data and collaborate with account teams to develop actionable clinical and benefit strategies
• Lead high-cost claimant reviews and implement targeted population health initiatives
• Partnering with the plan sponsor and Aetna account team to address concerns, resolve issues, and manage high-cost claimants in collaboration with external vendors as needed
• Conducting proactive outreach to targeted populations to support care coordination and improve health outcomes
• Serving as the direct contact for plan escalations and benefit-related inquiries from members or the plan sponsor
• Educating internal and external stakeholders on narrow network utilization and home-host steerage strategies
• Collaborating with Utilization Management on complex cases to ensure seamless care transitions
• Reviewing reports from the account team and CPC to identify outreach opportunities, support domestic steerage, and analyze data for improved member engagement
• Participating in annual utilization reviews with the account team and key plan sponsor stakeholders
• Supporting special projects as assigned by HBS Leadership, the Account Team, or the Plan Sponsor
• Traveling to plan sponsor healthcare facilities (approximately 10–15%) for annual meetings, collaboration sessions, or open enrollment events as requested

Requirements:

• Active Registered Nurse (RN) license with 3–5 years of professional experience in the field
• 3–5 years of experience in Case Management, demonstrating effective coordination and patient advocacy
• Proficient in problem-solving and decision-making, with the ability to assess situations and implement appropriate solutions
• Strong organizational and time management skills
• Ability to work independently and thrive in a fast-paced environment
• Proven analytical and critical thinking skills to interpret data and identify opportunities
• Resolution-focused with exceptional attention to detail and collaborative problem-solving skills
• Flexibility to adjust work hours to meet member needs, including early mornings or evenings
• Solid understanding of medical terminology and its application in clinical settings
• Demonstrated digital literacy, including the use of electronic health records and other healthcare technologies
• Strong interpersonal skills with the ability to communicate tactfully and respectfully with patients, families, and community members
• Proven ability to manage sensitive information with integrity, confidentiality, and ethical responsibility
• Skilled in evaluating costs and benefits of various options to determine the most effective course of action
• Capable of working effectively in diverse clinical environments, respecting cultural differences among staff and patients
• Based on location there may be 0-10% travel required on a very limited basis. Must possess reliable transportation and be willing and able to travel. Mileage is reimbursed per our company expense reimbursement policy

Benefits:

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

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