Case Manager RN

CVS Health

1d•Remote

About The Position

This Case Manager RN position is a fully remote role, welcoming candidates from any state, with a preference for those in compact RN states. The RN Case Manager is responsible for telephonically and/or face-to-face assessment, planning, implementation, and coordination of all case management activities with members. The primary goal is to evaluate members' medical needs and facilitate their overall wellness. This involves developing proactive courses of action to enhance short and long-term outcomes and integrate opportunities for overall wellness. Utilizing clinical tools and data, the Case Manager evaluates member needs, benefit plan eligibility, facilitates integrative functions, and ensures smooth transitions to Aetna programs. Clinical judgment is applied to reduce risk factors, address barriers, and manage complex health and social indicators impacting care planning. Assessments are comprehensive, considering various sources for co-morbid and multiple diagnoses affecting functionality, and reviewing prior claims. The role also includes assessing work capacity, restrictions, and limitations, and using a holistic approach to determine the need for referrals to clinical resources. Collaboration with supervisors and participation in case conferences are essential for overcoming barriers and multidisciplinary claim management. All processes must comply with regulatory and company policies, and strong interviewing skills are required for member engagement and health status discernment.

Requirements

Must have active, current and unrestricted RN Licensure in state of residence
3+ years clinical practice experience required
Must be able to work Monday through Friday 9:00am to 5:30pm time zone of residence
Must be able to work occasional holiday on-call as needed
Associates Degree required

Nice To Haves

Compact RN licensure
Case management experience
Bilingual in Spanish and English
Case Manager Certification
Experience with using Windows/ Microsoft Office
Strong computer skills
BSN Preferred

Responsibilities

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.
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 consider 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 for multidisciplinary focus to benefit overall claim 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.