Case Manager, Registered Nurse - Field IL (Cook County)

CVS Health•Chalmers, IL

22d•Remote

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Location: This role will be work at home with 50-75% travel within Cook County, IL and surrounding area. Candidates must live in or near: Elk Grove Village, Des Plaines, Park Ridge, Bensenville, Carol Stream, Hanover Park, Itasca. Medinah, Schaumburg, Hoffman Estates, Wooddale Norwood Park, Edison Park. Schedule: Standard business hours Monday-Friday 8:00am-5:00pm CST. Position Summary/Program Overview Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. 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. 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 Our Case Managers 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. Fundamental Components & Physical Requirements 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. Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services. Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. Prepares all required documentation of case work activities as appropriate. Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. Provides educational and prevention information for best medical outcomes. Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data. Utilizes case management processes in compliance with regulatory and company policies and procedures. Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work. 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/client’s overall wellness through integration. Monitors member/client progress toward desired outcomes through assessment and evaluation.

Requirements

Active and unrestricted Registered Nurse License in Illinois.
Minimum 3-5 years clinical practical experience preference required.
Minimum 2-3 years CM, discharge planning and/or home health care coordination experience.
Must possess reliable transportation and be willing and able to travel up to 75% of the time. Mileage is reimbursed per our company expense reimbursement policy.
Candidates must live in or near: Elk Grove Village, Des Plaines, Park Ridge, Bensenville, Carol Stream, Hanover Park, Itasca. Medinah, Schaumburg, Hoffman Estates, Wooddale Norwood Park, Edison Park.

Nice To Haves

Certified Case Manager is preferred.
Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually.
Excellent analytical and problem-solving skills.
Effective communications, organizational, and interpersonal skills.
Ability to work independently.
Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.
Efficient and Effective computer skills including navigating multiple systems and keyboarding.

Responsibilities

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.
Interacts with members/clients telephonically or in person.
May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services.
Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate.
Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.
Prepares all required documentation of case work activities as appropriate.
Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.
May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.
Provides educational and prevention information for best medical outcomes.
Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources.
Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.
Utilizes case management processes in compliance with regulatory and company policies and procedures.
Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
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/client’s overall wellness through integration.
Monitors member/client progress toward desired outcomes through assessment and evaluation.

Benefits

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an 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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