Case Manager RN- Johnson/Wyandotte Counties

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A Brief Overview

Coordinates all case management activities with members to evaluate medical needs and to facilitate the overall wellness of members.

Develops strategy to address issues to outcomes and opportunities to enhance member's overall wellness through integration.

Instructs programs and procedures in compliance with network management and clinical coverage policies.

What you will do

• Executes evaluation of member needs and benefit plan eligibility and facilitates member transition to the organization's programs and plans.
• Applies advanced clinical judgement to incorporate strategies designed to reduce risk factors and barriers, and to address complex health indicators that impact care planning and resolution of member issues.
• Handles reviews of prior claims to address potential impact on current case management and eligibility.
• Creates a holistic approach to assess the need for referrals to clinical resources and to assist in determining functionality.
• Ensures case management processes follow organization and regulatory requirements.
• Implements systems to maximize member engagement, discern health status and needs, and to assess member levels of work capacity and restrictions.
• Coaches and trains junior colleagues in techniques, processes, and responsibilities.

For this role you will need Minimum Requirements

• Basic awareness of problem solving and decision making skills
• 50-75% of travel required to meet members face to face in Johnson County and surrounding Counties.

Monday-Friday 8am- 5pm with flexibility needed to meet member needs.

This role will be supporting children that are on the technology assistance (TA) waiver.

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.

Nurse Case Manager is responsible for telephonic 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. Services strategies policies and programs are comprised of network management and clinical coverage policies.

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.

Required Qualifications :

• Active and unrestricted RN licensure in the state of KS.
• 1+ years of clinical experience.
• Willing and able to travel 50-75% of the time to meet members face to face in Johnson / Wyandotte and surrounding counties.
• Reliable transportation is required and mileage reimbursement is eligible based on company policy.

Preferred Qualifications :

• Case Management in an integrated model.
• 1+ years experience in Home and Community based Services experience.
• Managed Care Experience.
• Computer literacy and demonstrated proficiency is required in order to navigate through internal / external computer systems, and MS Office Suite applications, including Word and Excel.

Education :

• Associate's degree required
• Bachelor's degree preferred

Pay Range

The typical pay range for this role is :

$60,522.80 - $129,600.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.

The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ( PTO ) or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.