Case Manager Registered Nurse- Work at Home

About the position At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary This RN Case Manager role is 100% remote and the employee can live in any state and telework, however, there is a preference for an RN in a Compact RN state. Normal hours are Monday through Friday 8:00am – 4:30pm in the time zone of residence with occasional late shift rotation until 9:00pm. Employees can flex their 8-hour shift between 8:00am-6:00pm. There are no weekends or holiday shifts required at this time. Travel of less than 5% may be required in the event of clinical audits. The RN Case Manager is responsible for 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 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 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.

Responsibilities

• 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.
• 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.
• 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.

Requirements

• Must have an active, current and unrestricted RN license in state of residence
• Willingness and ability to obtain additional state licenses upon hire (paid for by the company)
• 3+ years of acute hospital clinical experience as an RN (general medical, post-surgical, ICU experience).
• 1+ years of experience with all types of Microsoft Office including PowerPoint, Excel, and Word
• Must be willing and able to travel of less than 5% in the event of clinical audits.
• Normal hours are Monday through Friday 8:00am – 4:30pm in the time zone of residence with occasional late shift r

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