Case Manager

About This Role

Caring for members by assessing, planning, implementing, and coordinating all case management activities is the core of this role. The RN Case Manager evaluates medical needs to facilitate overall wellness, working telephonically or face-to-face with individuals.

Responsibilities

• Develop a proactive course of action to address issues presented to enhance short and long-term outcomes
• Enhance a member’s overall wellness through integration
• Conduct an evaluation of member’s needs and benefit plan eligibility using clinical tools and information/data review
• Facilitate integrative functions and smooth transition to Aetna programs and plans
• Apply clinical judgment to incorporate strategies designed to reduce risk factors and barriers
• Address complex health and social indicators which impact care planning and resolution of member issues
• Consider information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality
• Review prior claims to address potential impact on current case management and eligibility
• Assess 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 using a holistic approach
• Consult with supervisor and others in overcoming barriers in meeting goals and objectives
• Present cases at case conferences for multidisciplinary focus to benefit overall claim management
• Utilize case management processes in compliance with regulatory and company policies and procedures
• Utilize interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation

Requirements

• Registered Nurse with active and unrestricted RN licensure in their state of residence, preferably with multi-state/compact privileges
• Ability to be licensed in all non-compact states
• 3+ years clinical practice experience
• Associate's degree

Nice to have:

• Compact RN licensure
• Case management experience
• Case Manager Certification
• Experience with using Windows / Microsoft Office
• Strong computer skills
• Bilingual (English/Spanish) speaking
• Bachelor’s degree

Benefits

• CVS Health bonus, commission or short-term incentive program eligibility
• Comprehensive benefits package
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options