Case Manager RN- High Point, NC

About the position

The Case Manager RN role at CVS Health is a telework/hybrid position that requires the candidate to be within driving distance of the High Point, North Carolina office. This position is designed for a Registered Nurse who will be responsible for telephonically assessing, planning, implementing, and coordinating all case management activities with members. The primary goal is to evaluate the medical needs of the members to facilitate their overall wellness. The role involves developing proactive strategies to enhance both short and long-term outcomes for members, ensuring that their health needs are met through a comprehensive and integrative approach. In this role, the RN Case Manager will utilize clinical tools and data review to conduct thorough evaluations of members’ needs and benefit plan eligibility. This includes facilitating smooth transitions to Aetna programs and plans. The RN will apply clinical judgment to incorporate strategies aimed at reducing risk factors and addressing complex health and social indicators that impact care planning and the resolution of member issues. Assessments will consider information from various sources, including co-morbid conditions and multiple diagnoses that affect functionality. The RN Case Manager will also review prior claims to understand their potential impact on current case management and eligibility. Assessments will include evaluating the member’s work capacity and any related restrictions or limitations. A holistic approach will be taken to assess the need for referrals to clinical resources that can assist in determining functionality. The RN will consult with supervisors and other team members to overcome barriers in meeting goals and objectives, and will present cases at case conferences to ensure a multidisciplinary focus on overall claim management. Compliance with regulatory and company policies and procedures is essential, as is the use of effective interviewing skills to engage members and discern their health status and needs through key questions and conversations.

Responsibilities
• Telephonically assess, plan, implement, and coordinate all case management activities with members.
,
• Develop proactive strategies to enhance short and long-term outcomes for members.
,
• Conduct evaluations of members’ needs and benefit plan eligibility using clinical tools and data review.
,
• Facilitate smooth transitions to Aetna programs and plans.
,
• Apply clinical judgment to reduce risk factors and address complex health and social indicators impacting care planning.
,
• Review prior claims to assess their impact on current case management and eligibility.
,
• Evaluate members’ work capacity and related restrictions/limitations.
,
• Utilize a holistic approach to assess the need for referrals to clinical resources.
,
• Consult with supervisors and team members to overcome barriers in meeting goals and objectives.
,
• Present cases at case conferences for a multidisciplinary focus on claim management.
,
• Ensure compliance with regulatory and company policies and procedures.
,
• Utilize interviewing skills to engage members and assess their health status and needs.

Requirements
• Active RN license in the state of North Carolina.
,
• Experience in case management or a related field.
,
• Strong clinical assessment skills and the ability to apply clinical judgment.
,
• Excellent communication and interpersonal skills for member engagement.
,
• Ability to work independently and manage time effectively in a telework environment.

Nice-to-haves
• Experience with Aetna programs and plans.
,
• Knowledge of regulatory requirements in case management.
,
• Familiarity with telehealth practices and technologies.

Benefits
• Work from home option available.
,
• Flexible working hours with occasional evening, weekend, and holiday shifts as needed.