Case Manager RN - Field

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 This is a full-time field teleworker position that requires West Virginia residency. Travel is required 50% of the time or more, in the Central region of WV. Field based travel locations may include member homes, residential treatment facilities, group homes, shelters, and detention facilities. Qualified candidates must reside in the region, in one of the following counties:
Roane, Calhoun, Gilmer, Kanawha, Clay, Braxton, Fayette, Nicholas, or Webster.

The Case Manager RN (CM RN) is responsible for telephonically and/or face to face 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. This position is heavy community-based with some onsite presence at Department of Health and Human Resources (DHHR) offices. Schedule is Monday - Friday, 8am-5pm, standard business hours. No nights, weekends, or holidays. A flexible work schedule may be available after 6 months of service and with demonstrated performance and attendance.

Fundamental Components:
• Conducts face to face member visits
• Using 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.
• Assesses information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.
• Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
• Effective communication skills, both verbal and written.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.

Required Qualifications
• Registered Nurse with current unrestricted West Virginia (WV) license or Registered Nurse with current unrestricted WV or "multi-state privilege" license
• 5+ years' clinical practice experience
• 2+ years' experience with personal computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint, Teams)
• Must possess reliable transportation and be willing and able to travel in the assigned region 50% or more, of the time. Mileage is reimbursed per our company expense reimbursement policy

Preferred Qualifications
• Medicaid experience.
• Waiver experience
• Foster care experience
• Crisis intervention skills
• Managed care/utilization review experience
• Certified Case Manager (CCM) certification
• Case management experience in an integrated model
• Case management and discharge planning experience
•…