A1A Precertification Nurse

Precertification Nurse 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:

Must reside within 45 miles to office locations in New Albany, OH, Chandler, AZ or High Point, NC.

The Precertification Nurse Case Manager is responsible for reviewing medical records to determine the medical necessity for elective procedures. They are responsible for communicating the current status and determinations to our providers and members, as well as guide the members, through the health care system. They assess the members conditions and coordinate care with our care management team, telephonically assessing, planning, implementing and coordinating activities with members to evaluate the medical needs of the member, to facilitate the member's overall wellness.

Fundamentals:

• Evaluates benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• Reviews for plan nuances and requirements including (institute of quality) IOQ requirements, benefit exclusions, second opinion requirements and claims history to address potential impact on current case review and eligibility.
• Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
• Conducts routine utilization reviews and assessments, applying evidence-based criteria including internal clinical policy bulletins (CPB) and Milliman care guideline (MCG) and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services related to elective procedures.
• Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
• Strategizes clinical review, prioritizing various items including escalations, dates of services and case type to maintain standard timeliness guidelines.
• Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Monitoring for high cost claims and need for additional support from the health care team.
• Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
• Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
• Reviews for accurate level of care and monitors length of stay to ensure members are at the appropriate level of case and to assess for discharge planning needs.
• Using a holistic approach assess the need for a referral to clinical resources for assistance in navigation of the healthcare system.
• Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.
• Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.
• Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.
• Consults with supervisor and others in overcoming barriers in meeting goals - and objectives, presents cases at medical director rounds or care calls for a multidisciplinary focus to benefit overall member management.

Required Qualifications:

- Must have active, current and unrestricted compact RN state licensure

- Must reside within 45 miles to office locations in New Albany OH, Chandler AZ or High Point NC- 3+ years of clinical practice experience required

- Must be able to work Monday through Friday 8:00 AM to 4:30 PM, in your local time zone with evening rotation required about 2 times a month until 8pm, EST.

- This position is work from home, however may include on site work requirements from time to time including; team meetings, colleague trainings, customer visits, performance related issues, and other business needs.

- 2+ years of experience using Microsoft Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Preferred Qualifications:

Ability to organize, multitask, prioritize and work in a fast pace…