, North Carolina

Job Description
Monday-Friday standard business hours. This could change due to business needs.

This role is a blended role doing both Case Management and Utilization Management.

This is a fully telework role. Applicants must reside in a compact state.

Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the transplant member's needs and to facilitate the member’s overall well-being. 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-morbid and multiple diagnoses that impact functionality. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Collaborates with the Transplant provider and member to achieve optimal outcomes for the transplant member. Consults with Medical Director, 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.

Required Qualifications
-An active and good standing compact state RN license required
-2+ years experience in critical care
-5+ years clinical practice experience
- Case management or Utilization Management experience required

Preferred Qualifications
-Transplant experience preferred
-Case Management Certification preferred

Education
Associates Degree in Nursing

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.


We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities. See Job Description

, North Carolina

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