Case Manager RN
About The Position
The RN Case Manager uses a collaborative process of assessment, planning, facilitation, and advocacy to connect members with options and services that meet their benefit-plan and health needs. The role uses clinical tools and data review to assess referred members’ needs and eligibility, evaluate benefit plans and available programs, and determine approaches to resolving cases and meeting member needs. The Case Manager applies clinical criteria, guidelines, standardized case-management plans, policies, procedures, and regulatory standards to support appropriate benefit administration and compliant, cost-effective outcomes. The position works with members and their care teams to develop and monitor plans of care, conduct comprehensive clinical assessments, address risk factors and complex clinical indicators, and support members experiencing behavioral-health or medical crises. The role also collaborates with supervisors, Medical Directors, multidisciplinary teams, providers, and community resources; identifies and escalates quality-of-care concerns; and uses motivational interviewing, coaching, and member education to encourage engagement and informed healthcare decisions. Most work consists of telephone outreach and documentation in a clinical case-management platform. Standard business hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern Time. The employee needs a quiet, dedicated workspace without distractions and must connect to the modem by wired connection. The role may involve community field visits for up to 20% of the time. The position is based in a typical office work environment and requires extended sitting, telephone conversations, typing, and close inspection of documents and a computer monitor. The candidate must reside in one of the specified Michigan counties.
Requirements
- Active, unrestricted RN license in the state of Michigan.
- Must reside in one of the following Michigan counties: Berrien, Van Buren, Cass, Kalamazoo, St. Joseph, Calhoun, Branch, Jackson, Hillsdale, Livingston, Washtenaw, Lenawee, Monroe, Oakland, Macomb, Wayne, Clinton, Eaton, or Ingham.
- Proficiency with computer skills, including navigating multiple systems and keyboarding.
- Effective verbal and written communication skills.
- Ability to multitask, prioritize, and adapt effectively in a fast-paced environment.
- Ability to work in a quiet, dedicated workspace without distractions and connect to the modem using a wired connection.
- Ability to perform sedentary work involving extended sitting, telephone conversations, listening, and computer typing.
- Ability to closely inspect handwritten and computer-generated documents and a PC monitor.
Nice To Haves
- Three years of clinical practice experience, such as in a hospital, home health, or ambulatory care setting.
- Three or more years of Maternity/NICU experience.
- Experience managing the CSHCS (Children’s Special Health Care Services) population.
- Healthcare and/or managed-care industry experience.
Responsibilities
- Collaborate with members and their care teams to develop and monitor plans of care that support member goals.
- Conduct comprehensive assessments of referred members’ needs and eligibility using clinical tools and data review.
- Evaluate benefit plans and internal and external programs or services to determine how to resolve cases and meet member needs.
- Apply clinical judgment and strategies to reduce risk factors and address complex clinical indicators affecting care planning and case resolution.
- Perform crisis intervention for members experiencing behavioral-health or medical crises, refer them to appropriate clinical providers, and provide crisis follow-up.
- Apply or interpret applicable criteria, clinical guidelines, standardized case-management plans, policies, procedures, and regulatory standards when assessing benefits and member needs.
- Consult with supervisors, Medical Directors, and other programs to address barriers; present cases at conferences to obtain multidisciplinary input.
- Identify and escalate quality-of-care issues through established channels.
- Communicate with medical and behavioral-health professionals to influence appropriate member care.
- Use motivational interviewing to engage members and promote lifestyle or behavioral changes.
- Coach and support members so they can make independent medical and healthy-lifestyle choices and participate knowledgeably in healthcare decisions.
- Analyze utilization, self-reported, and clinical data to identify comprehensive member needs.
- Conduct telephone outreach and document work in a clinical case-management platform.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources to support colleagues’ physical, emotional, and financial well-being
- Eligibility for a CVS Health bonus, commission, or short-term incentive program
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
