CVS Health Nurse Case Manager RN in St Louis, Missouri
Registered Nurse experience in field of case management with experience in managed care or insurance. Required 5 years’ experience as an RN; that includes a clinical background experience. Hospital nursing experience required. Prefer candidates with a strong background in one of the following: Oncology, BH/SA or Transplant as well as a CCM and/or other URAC recognized accreditation. This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. This is a work at home position and all training is virtual.
Enhancement of Medical Appropriateness and Quality of Care:
-Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits.
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.
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.
-Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
Utilizes case management processes in compliance with regulatory and company policies and procedures.
Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
-Identifies and escalates member's needs appropriately following set guidelines and protocols.
5 years experience as a Registered Nurse with hospital experience and Case Management experience required (Nurse navigator/coordinator role).
Current or previous experience in Oncology, Transplant, Behavior Health/Substance Abuse, etc. preferred.
Discharge planning experience from/to and transferring to lower levels of care.
Multiple state RN licensure required upon hire.
Need to actively reach out to members to collaborate/guide their care.
Perform medical necessity reviews.
Requires ability to document electronically using keyboard and multiple computer screens--free form text/good typing skills, experience with MCG, NCCN, Lexicomp a plus.
Additional Job Information
Work at home office environment with productivity and quality expectations while keeping office private. Office furniture supplied by employee: chair, desk, footrest.
Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
Effective communication skills, both verbal and written.
Bachelor's degree or equivalent experience
Percent of Travel Required
0 - 10%
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.
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