Clinical Case Manager

CVS Health • Carapichaima, IL

2d

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/Mission Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. Fundamental Components & Physical Requirements Include but are not limited to: Assessment of Members Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues. Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services. Enhancement of Medical Appropriateness and Quality of Care Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefit Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes Identifies and escalates quality of care issues through established channels -Ability to speak to medical and behavioral health professionals to influence appropriate member care. Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/ behavior changes to achieve optimum level of health Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. Helps member actively and knowledgably participate with their provider in healthcare decision-making. Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs. Monitoring, Evaluation and Documentation of Care In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures. Exhibits the following Clinical Case Manager

Requirements

• Candidate must have active and unrestricted Illinois Registered Nurse (RN) License
• 3-5 years clinical practical experience
• 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
• Effective computer skills including navigating multiple systems and keyboarding
• Demonstrates proficiency with standard corporate software applications, including Microsoft Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications
• Associate’s Degree in Nursing (REQUIRED)

Nice To Haves

• 2-3 years of care management, discharge planning and/or home health care coordination experience
• Bachelor’s Degree in Nursing (PREFERRED)

Responsibilities

• Assessment of Members Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
• Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefit
• Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
• Identifies and escalates quality of care issues through established channels -Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/ behavior changes to achieve optimum level of health
• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Helps member actively and knowledgably participate with their provider in healthcare decision-making.
• Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
• In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree