[Hiring] Case Manager Registered Nurse @CVS Health

Role Description

This Case Manager RN position is with Aetna’s National Medical Excellence (NME) team and is a fully remote position. Candidates from any state are welcome to apply, however, preference is for candidates in compact RN states. This role is a blended role doing both Case Management and Utilization Management.

• 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.
• Conducts an evaluation of member’s needs and benefit plan eligibility through the use of clinical tools and information/data review, facilitating integrative functions and smooth transition to Aetna programs and plans.
• Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators impacting 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, assesses 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, presenting 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.

Qualifications

• Must have an active, current and unrestricted compact RN licensure in the state of residence
• 5 years clinical practice experience as an RN
• 2+ years’ experience in critical care
• 6+ months Case Management or Utilization Management experience
• Must be able to work Monday through Friday 8:00am to 5:00pm in the time zone of residence
• Must be able to obtain multi state RN licensures (expense paid for by organization)

Preferred Qualifications

• Case Management Certification
• Transplant experience

Education

• Associate Degree in Nursing required
• BSN preferred

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources, based on eligibility