Case Manager - Registered Nurse - South Region

Community Care Case Manager

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.

Position Summary Community Care Case Manager use a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.

Responsibilities include:

• Acting as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.
• Implementing and coordinating all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.
• Interacting with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician's office to provide ongoing case management services.
• Assessing and analyzing injured, acute, or chronically ill members/clients medical and/or vocational status; developing a plan of care to facilitate the member/client's appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate.
• Communicating with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.
• Preparing all required documentation of case work activities as appropriate.
• Interacting and consulting with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.
• May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.
• Providing educational and prevention information for best medical outcomes.
• Applying all laws and regulations that apply to the provision of rehabilitation services; applying all special instructions required by individual insurance carriers and referral sources.
• Testifying as required to substantiate any relevant case work or reports.
• Conducting an evaluation of members/clients' needs and benefit plan eligibility and facilitating integrative functions using clinical tools and information/data.
• Utilizing case management processes in compliance with regulatory and company policies and procedures.
• Facilitating appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
• Developing 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/client's overall wellness through integration.
• Monitoring member/client progress toward desired outcomes through assessment and evaluation.

Required Qualifications

• Candidate must reside in the South Region: OH, VA, NC, KY, TN, SC, GA, AL, MS, AR, LA, FL
• Candidate must have active and unrestricted Compact Registered Nurse (RN) Licensure in OH or in their state of residence
• 3+ years clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac) with Medicare members
• 2+ years case management, discharge planning and/or home health care coordination experience

Preferred Qualifications

• Bilingual - Spanish
• Excellent analytical and problem-solving skills
• Effective communications, organizational, and interpersonal skills.
• Ability to work independently (may require working from home)
• Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some…