in United States, Ohio

Description Are you a paediatric speech language therapist with excellent communication skills? A fantastic opportunity has opened for paediatric speech language therapist to join a well-established client based in Cleveland. This position is available for the appointed speech and language therapist to start as soon as possible, offering full-time hours per week, in a locum role. The successful speech therapist will be compassionate and dedicated, providing assessment and therapeutic interventions to school aged children with dysphagia. Working as part of a multi-disciplinary team, the speech therapist will be an integral member, supporting the children using visual support, EHCPs and AAC approaches. What Next? If you feel that you are a supportive and compassionate speech therapist, then please apply today. Why Pulse? • HireVue online interviews • Advice and support from our team of dedicated and experienced consultants • Our vacancies offer and true work/life balance • Daily payroll • Access to high-quality voluntary training • ipoint – Electronic timesheet processing app • £300 recommend a friend bonus scheme* • Variety of opportunities in both NHS and private sectors  • Assistance with travel and finding accommodation *Terms and conditions apply

This position will be full time telework and will be expected to work 11:30A - 8P ESTUtilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.Fundamental ComponentsUtilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for membersGathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of careCommunicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilizationConsults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

Enhancement of Medical Appropriateness and Quality of Care:-Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits.-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.-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.-Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.-Utilizes case management processes in compliance with regulatory and company policies and procedures.-Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.-Identifies and escalates member's needs appropriately following set guidelines and protocols.

Help us elevate our patient care to a whole new level! Join our Community Care team as an industry leader in serving our members by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Community Care members.Community Care is a member centric, team-delivered, community-based care management model that joins members where they are.With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country. Family Summary/Mission Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Position Summary/Mission Community Care Case Manager use a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes. Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate. • Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care. Other duties as assigned

Utilizes clinical skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. Remote internals must be near one of these Aetna offices: Illinois, Michigan, Ohio, New Jersey or Virginia.Monday-Friday standard business hours. Occasional weekend and holiday. No nights!Promotes/supports quality effectiveness of Healthcare Services and benefit utilization Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit administration Collects information to support the process of rendering appropriate medical necessity/benefit determinations Identifies members for referral opportunities to integrate with other products, services and/or programs Utilizes clinical experience, criteria/guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.Schedule is Monday-Friday standard business hours.No nights!Rotating weekends (3) and holidays(1).Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care(*) Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)(*) Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment(*) Identifies members who may benefit from care management programs and facilitates referral(*) Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization(*)

We are currently recruiting top talent for our Outbound Service Advocate role in our Member Advocacy Center (Medicare Stars MAC Team). Aetna Medicare’s Member Advocacy Center outreaches to our members to provide innovative, proactive and compassionate solutions that exceed our member’s expectations. We are the knowledgeable, trusted, advocates for our members. The key to our success is our people. This position requires answering questions and resolving issues based on outbound phone calls to Medicare members. This position requires a high degree of empathy and patience. This position also requires performing a review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible and educating the member on their plan of benefits based on the outbound campaign.A Medicare Member Advocate will: Educates plan benefits, answers questions and resolves issues based on outreach campaign calls.Documents and tracks contacts with members.Educates members on our self-service optionsFollows campaign guidelines for exceptional serviceExceeds member expectationsEnsures that every caller is treated with respect, kindness and all questions are thoroughly answeredRespond to inquiries from our Medicare Advantage membersConducts targeted outbound calls to diminish service disruption and educate members on new plansTakes ownership and follows through on commitmentsCreate lasting relationships with our membersWork in a team environment to create world class serviceAbility to navigate multiple systemsActs as an advocate for our members

Nurse Case Manager is responsible for telephonically and/or 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. 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.Territory travel is within the following four counties in Ohio: Fulton, Wood, Lucas and Ottawa. Highly prefers a candidate to reside within one of these 4 counties.Schedule is Monday-Friday standard business hours. No nights, no weekends and no holidays.

Job DescriptionUtilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence based care and clinical practice guidelines for Behavioral Health and/or medical conditions based upon program focus.Location is Cincinnati, SW Region (counties Hamilton, Butler, Warren, Clermont, and Clinton) of Ohio. Must reside within 20 miles.Local travel is 25-50%.Schedule is Monday-Friday standard business hours.No nights, no weekends and no holidays!Fundamental ComponentsUtilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, apply evidence based standards and practice guidelines to treatment where appropriate. Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Provides triage and crisis support. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage. determination/recommendation along the continuum of care facilitates including effective discharge planning. Coordinates with providers and other parties to facilitate optimal care/treatment. Identifies members at risk for poor outcomes and facilitates referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

POSITION SUMMARY:Aetna Better Health of Ohio (An Aetna Duals Eligible Medicaid Plan) is looking for a Medical Director to join our team. The Medical Director will provide oversight for medical policy implementation and participate in the development, implementation, and evaluation of clinical/medical programs.This can be a Work at Home position / Previous Managed care Experience Desired. Expands Aetna's medical management programs to address member needs across the continuum of care. This may include Medicare-Medicaid Dual Eligible members in Ohio, Illinois, Michigan, and Virginia.Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Reviews prior authorization and concurrent review cases and provides decisions on those cases regarding services to members.Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. Acts as clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Responsible for predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise.