Case Manager Registered Nurse RN

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 Case Manager RN position is a fully remote position. Candidates from any state are welcome to apply, however, preference is for candidates in compact RN states. Normal Working Hours: Monday-Friday 9:00am - 5:30pm (9:00am being the earliest start time) in the time zone of residence. Team is open to varying hours until 8:00pm EST. There is a late shift rotation until 8:00pm EST and holiday on-call as needed. There is no travel expected with this position. 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. RN Case Manager: 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.

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.
• 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.

Requirements

• Must be a Registered Nurse with active current and unrestricted RN licensure in state of residence.
• Must have the ability to obtain multi-state/compact licensure and the ability to be licensed in all states.
• CVS supporting the cost of required licensure
• 3+ years clinical practice experience as an RN required
• Must be willing and able to work Monday through Friday 9:00am - 5:30pm (9:00am being the earliest start time) in the time zone of residence. Team is open to varying hours until 8:00pm EST. There is a late shift rotation until 8:00pm EST and holiday on-call as needed
• 1+ years of MS Office Suites (Outlook, Word, Excel) experience

Nice-to-haves

• Compact RN licensure
• Case management experience preferred.
• Case Manager Certification.
• BSN preferred

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.

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