Case Manager - Registered Nurse - South Region

CVS Health

1d•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary 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. 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. Testifies as required to substantiate any relevant case work or reports. 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

Candidate must reside in the South Region: OH, VA, NC, KY, TN, SC, GA, AL, MS, AR, LA, FL
Candidate must have active and unrestricted Compact Registered Nurse (RN) Licensure in OH or in their state of residence
3+ years clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac) with Medicare members
2+ years case management, discharge planning and/or home health care coordination experience
Associate's Degree or Nursing Diploma (REQUIRED)
Active and unrestricted Compact Registered Nurse (RN) Licensure in OH or in their state of residence

Nice To Haves

Bilingual - Spanish
Excellent analytical and problem-solving skills
Effective communications, organizational, and interpersonal skills.
Ability to work independently (may require working from home)
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
Willing and able to obtain multi state Registered Nurse (RN) licenses if needed, company will provide
Certified Case Manager National professional certification (CRC, CDMS, CRRN, COHN, or CCM)
Bachelor's Degree (PREFERRED)

Responsibilities

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.
Act as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.
Implement and coordinate 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.
Interact 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.
Assess and analyze injured, acute, or chronically ill members/clients medical and/or vocational status; develop 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.
Communicate with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.
Prepare all required documentation of case work activities as appropriate.
Interact and consult 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.
Provide educational and prevention information for best medical outcomes.
Apply all laws and regulations that apply to the provision of rehabilitation services; apply all special instructions required by individual insurance carriers and referral sources.
Testify as required to substantiate any relevant case work or reports.
Conduct an evaluation of members/clients’ needs and benefit plan eligibility and facilitate integrative functions using clinical tools and information/data.
Utilize case management processes in compliance with regulatory and company policies and procedures.
Facilitate appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
Develop 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.
Monitor member/client progress toward desired outcomes through assessment and evaluation.