Case Manager Registered Nurse – Field – reside Newport News Virginia Peninsula

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.

Assessment of members:
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.

- Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow-up to members to help ensure the members are receiving appropriate treatment and services.

- Enhancement of Medical Appropriateness and Quality of Care.

- Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits.

- Using holistic approach, consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes.

- Identifies and escalates quality of care issues through established channels; ability to speak to medical and behavioral health professionals to influence appropriate member care.

- Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior change to achieve optimum level of health; provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.

- Helps member actively and knowingly participate with their provider in healthcare decision‑making.

- Analyzes all utilization, self‑report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Monitoring, evaluation and documentation of care:
In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals, utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Responsible for 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‑morb and multiple diagnoses that impact functionality.

Reviews prior claims to address potential impact on current case…