Case Manager - Registered Nurse (EST)
About The Position
Nurse Case Manager is responsible for telephonically 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. Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. 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. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member’s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences to benefit overall medical management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
Requirements
- Candidate must be based in the Eastern Time Zone (US)
- 3+ years clinical practice experience
- Candidate must have an active and unrestricted Compact Registered Nurse (RN) License in the state of residence
- Candidate must be willing and able to obtain additional state licensure as needed
- Associate's Degree in Nursing (REQUIRED)
Nice To Haves
- Bilingual English/Spanish
- Managed care experience
- CCM Certification
- Bachelor's Degree in Nursing (PREFERRED)
Responsibilities
- Telephonically 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
- Conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans
- 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
- Reviews prior claims to address potential impact on current case management and eligibility
- Assessments include the member’s level of work capacity and related restrictions/limitations
- Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality
- Consults with supervisor and others in overcoming barriers in meeting goals and objectives
- Presents cases at case conferences to benefit overall medical management
- Utilizes case management processes in compliance with regulatory and company policies and procedures
- Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
- CVS Health bonus, commission or short-term incentive program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
