Case Manager RN

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Job Description

The dedication of talented and caring health care professionals drives the

delivery of high quality, cost effective products and services. They make it

possible for members to get the right health care treatment for their needs

– and for Aetna to keep its competitive edge.

Facilitate the delivery of appropriate benefits and/or healthcare information

which determines eligibility for benefits while promoting wellness activities.

Develops, implements and supports Health Strategies, tactics, policies and

programs that ensure the delivery of benefits and to establish overall

member wellness and successful and timely return to work. Services and

strategies, policies and programs are comprised of network management,

clinical coverage, and policies.

The Case Manager uses a collaborative process of assessment, planning,

facilitation, care coordination, evaluation, and advocacy for options and

services to meet an individual's and family's comprehensive health needs

through communication and available resources to promote quality, cost

effective outcomes.

Acts as a liaison with member/client /family, employer, provider(s), insurance

companies, and healthcare personnel as appropriate. Implements and

coordinates all case management activities relating to catastrophic cases

and chronically ill members/clients across the continuum of care that can

include consultant referrals, home care visits, the use of community

resources, and alternative levels of care. Interacts with members/clients

telephonically or in person. May be required to meet with members/clients

in their homes, work-sites, or physician's office to provide ongoing case

management services.

Assesses and analyzes injured, acute, or chronically ill members/clients

medical and/or vocational status; develops a plan of care to facilitate the

member/client's appropriate condition management to optimize wellness

and medical outcomes, aid timely return to work or optimal functioning, and

determination of eligibility for benefits as appropriate.

Communicates with member/client and other stakeholders as appropriate

(e.g., medical providers, attorneys, employers and insurance carriers)

telephonically or in person.

Prepares all required documentation of case work activities as appropriate.

Interacts and consults with internal multidisciplinary team as indicated to

help member/client maximize best health outcomes.

May make outreach to treating physician or specialists concerning course of

care and treatment as appropriate.

Provides educational and prevention information for best medical outcomes.

Applies all laws and regulations that apply to the provision of rehabilitation

services; applies all special instructions required by individual insurance

carriers and referral sources.

Testifies as required to substantiate any relevant case work or reports.

Conducts an evaluation of members/clients' needs and benefit plan

eligibility and facilitates integrative functions using clinical tools and

information/data. Utilizes case management processes in compliance with

regulatory and company policies and procedures. Facilitates appropriate

condition management, optimize overall wellness and medical outcomes,

appropriate and timely return to baseline, and optimal function or return to

work. 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/client's overall wellness through integration. Monitors

member/client progress toward desired outcomes through assessment and

evaluation.

Required Qualifications

• Minimum 3 or more years clinical practical experience.

• Minimum 2 or more years case management, discharge planning and/or home health care coordination experience.

• Registered Nurse with active compact state license in good standing in IL is required.

COVID Requirements

CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.

If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications

• Bachelor's degree preferred.

• Certified Case Manager is preferred.

• Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) is preferred, but not required

• Excellent analytical and problem-solving skills

• Effective communications, organizational, and interpersonal skills.

• Ability to work independently (may require working from home).

• Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.

• Efficient and Effective computer skills including navigating multiple systems and keyboarding

• Willing and able to obtain multi state RN licenses if needed, company will provide.

Education

Associates degree required, Bachelors degree preferred

Business Overview

At CVS Health, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, sex/gender, sexual orientation, gender identity or expression, age, disability or protected veteran status or on any other basis or characteristic prohibited by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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Company info

CVS Health.
Website : https://www.cvshealth.com