Complex Nurse Case Manager- Field

Position Summary

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. The role evaluates the medical and psychosocial needs of members to facilitate and support improved health. The Case Manager develops proactive courses of action to address issues, enhance short and long‑term outcomes, and promote overall wellness.

Services, strategies, policies and programs include network management and clinical coverage policies. This is a field‑based position that requires routine regional in‑state travel (80‑90%) with personal vehicle use.

• Through clinical assessment tools and data review, conducts a comprehensive evaluation of member needs and benefit plan eligibility, facilitating integrative functions and smooth transition to Aetna programs.
• Applies clinical judgment to incorporate strategies that reduce risk factors and barriers, addressing complex health and social indicators impacting care planning.
• Integrates assessment data from all care partners to holistically manage physical and behavioral health conditions, including co‑morbidity and multiple diagnoses.
• Creates, monitors, and revises member care plans to address biopsychosocial needs.
• Reviews prior claims to address potential impacts on current case management and eligibility.
• Assesses functional capacity and related restrictions/limitations.
• Utilizes a holistic approach to assess the need for referrals to additional clinical resources.
• Consults with supervisor and care partners to overcome barriers and presents cases at multidisciplinary conferences.
• Uses case management processes in compliance with regulatory and company policies.
• Applies motivational interviewing to ensure member engagement and discern health status and needs.
• Encourages members to actively and knowledgeably participate with their provider in decision‑making.
• Works in a field‑based environment with productivity and quality expectations.
• Requires the ability to perform close inspection of handwritten and computer‑generated documentation.
• Engages in sedentary work involving periods of sitting, talking, listening.
• Requires sitting for extended periods, talking on the telephone and typing on the computer.
• Must be able to multitask, prioritize and adapt to a fast‑paced, changing environment.

• 5+ years of clinical practice experience.
• RN with current unrestricted state licensure.
• Experience or detailed knowledge of Foster Care, juvenile justice systems, Adoption Assistance, behavioral health services, trauma‑informed care, ACEs, crisis intervention and evidence‑based practices applicable to Kentucky SKY populations.
• Flexibility to work beyond core business hours (Monday‑Friday, 8:00‑5:00).
• Reliable transportation; mileage reimbursed per company policy.
• Must reside within the Lakes Region (list of counties).

• Case management experience in an integrated model.
• Bilingual preferred.
• Computer literacy and proficiency in MS Office and internal/external systems.
• Effective communication skills, both verbal and written.

• Associate’s degree required.
• BSN preferred.

40

Full time

The typical pay range for this role is:
$54,095.00 - $

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 experience, education, geography and other factors. The position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above.

This full‑time position is eligible for a comprehensive benefits package designed to support physical, emotional and financial well‑being of colleagues and their families. Benefits include medical, dental, vision coverage, paid time off, retirement savings options, wellness programs and other resources, based on eligibility.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.