, Pennsylvania

Job Description
This is open to telework anywhere.

This role is Monday-Friday 8:00am-4:30pm with occasional late shift required and rotating holidays.

Nurse Case Manager 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.

-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.

-Reviews prior claims to address potential impact on current case management and eligibility.

-Assessments include the members level of work capacity and related restrictions/limitations.

-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.

Required Qualifications
- 5 years of clinical practice experience required
- Ability to obtain multi-state licensure required upon hire (company paid)
-Strong computer skills required

Preferred Qualifications
- CCM preferred
- Case Management in an integrated model preferred
- Discharge Planning experience preferred
- Managed care experience preferred
- Multi-state RN licensure preferred

Education
- Associate's Degree or equivalent
- RN with current unrestricted state licensure required

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

, Pennsylvania

Continue serving and work with a purpose

As a CVS Health colleague, you'll find career opportunities across the organization and at every stage of your career. More important, your work will have an impactful purpose on someone's life, including your own. Learn more about how you can continue serving on your next mission at CVS Health.

Careers for Veterans and Military Spouses

 

"The military has an ethos that is grounded in purpose-driven service that’s bigger than the individual. The same holds true for us at CVS Health. You can talk to colleagues in any part of our business and they will be able to articulate our company’s purpose. Working here provides an opportunity for service members and military spouses to continue to serve, just in a civvies."

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