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Position Summary
The RN Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits. Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Standard business hours: Monday - Friday 8:00 am - 5:00 pm EST.
Candidates will need a quiet, dedicated work space with no distractions. This role will require that the candidate be hard wired into the modem. May spend up to 20% of time in the community for field visits.
Monitoring, Evaluation and Documentation of Care:
• In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
• Majority of time is spent on telephonic outreach and documentation in a clinical case management platform.
Assessment of Members:
• Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Enhancement of Medical Appropriateness and Quality of Care:
• Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
• Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
• Identifies and escalates quality of care issues through established channels
• Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• Utilizes motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health
• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Helps member actively and knowledgably participate with their provider in healthcare decision-making
• Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
Required Qualifications
Must have an active and unrestricted RN license in the state of Michigan.
Candidate MUST reside in one of these counties: Berrien, Van Buren, Cass, Kalamazoo, St. Joseph, Calhoun, Branch, Jackson, Hillsdale, Livingston, Washtenaw, Lenawee, Monroe, Oakland, Macomb, Wayne, Clinton, Eaton, or Ingham
Preferred Qualifications
-3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
-3 _ years of Maternity/NICU experience
-Experience preferred managing the CSHCS population (Children's Special Health Care Services)
-Healthcare and/or managed care industry experience required.
-Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
-Effective communication skills, both verbal and written.
-Ability to multitask, prioritize and effectively adapt to a fast paced environment
-Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
-Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
-Typical office working environment with productivity and quality expectations.
Education
Must have an active and unrestricted RN license in the state of Michigan.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$60,522.00 - $129,615.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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