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We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. The Complex Nurse Case Manager is responsible for assessing members through regular and consistent in person or telephonic contact to assess, plan, implement and coordinate all case management activities with members to evaluate the medical and psychosocial needs of the member to facilitate and support the member’s improved health. The 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. Services strategies policies and programs are comprised of network management and clinical coverage policies. This is a field-based position that requires routine regional in-state travel 80-90% of the time; use of personal vehicle is required. Travel to the Louisville office is also anticipated for meetings and training. This position is assigned to the Jefferson Region. Field-based working environment with productivity and quality expectations. Work requires the ability to perform close inspection of handwritten and computer-generate. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
Job Responsibility:
Assessing members through regular and consistent in person or telephonic contact to assess, plan, implement and coordinate all case management activities with members to evaluate the medical and psychosocial needs of the member to facilitate and support the member’s improved health
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
Conducts a comprehensive and holistic 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
Integrates assessment data from all care partners to holistically address all physical and behavioral health conditions including co-morbid and multiple diagnoses that impact functionality and member well-being
Creates, monitors and revise member care plans to comprehensively address member biopsychosocial care needs
Reviews prior claims to address potential impact on current case management and eligibility
Assesses the member’s functional capacity and related restrictions/limitations
Assesses the need for a referral to additional clinical resources for assistance in determining functionality
Consults with supervisor and other care partners to overcome 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 motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation
Helps member actively and knowledgably participate with their provider in healthcare decision-making
Requirements:
5+ years’ clinical practice experience
RN with current unrestricted state licensure required
Experience or detailed knowledge of the Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavioral Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, and evidence-based practices applicable to the Kentucky SKY populations, is required
Flexibility to work beyond core business hours of Monday-Friday, 8am-5pm, is required
Reliable transportation required
Nice to have:
Case Management experience in an integrated model
Bilingual preferred
Computer literacy and demonstrated proficiency in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel
Effective communication skills, both verbal and written
BSN preferred
What we offer:
Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access
Mileage is reimbursed per our company expense reimbursement policy