Complex Nurse Case Manager- Field- reside in Jefferson County, KY

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.

Coordinates all case management activities with members to evaluate medical needs and 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.

• 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.

• Basic awareness of problem solving and decision making skills
• Must reside in Jefferson County KY.

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. Qualified candidates must have valid KY driver’s license, proof of vehicle insurance, and reliable transportation. Travel to the Louisville office is also anticipated for meetings and training. This position is assigned to the Jefferson Region. Flexibility to work beyond core business hours of Monday-Friday, 8am-5pm, is required.

• Through the use of clinical assessment tools and evaluating information/data review, 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 revises 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.
• Using a holistic approach, 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…