Case Manager RN
5 days ago
As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Work at home with requirement to reside in Illinois. Preference for those residing in Cook County or surrounding areas.
Potential for up to 15% of travel for occasional face to face visits with members and travel to Downers Grove/Chicago office for meetings.
Monday- Friday 8:00 am-5:00 pm.
Position Summary
Utilizes advanced clinical judgement and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization resources and optimal, cost-effective outcomes.
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 influencing/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.
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.
Required Qualifications
-Minimum of 2 years of clinical experience as an RN.
-Must possess active and unrestricted RN license in the state of Illinois.
-Willing and able to travel up to 15% of their time to meet members face to face and for onsite meetings within Cook County IL and surrounding areas/counties (Chicagoland area).
-Reliable transportation required; Mileage is reimbursed per our company expense reimbursement policy.
- 2+ years' experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
Preferred Qualifications
-Crisis intervention skills preferred
-Managed care/utilization review experience preferred
-Case management and discharge planning experience
preferred.
Education Minimum of a Associate's degree required; BSN preferred.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$66,575.00 - $142,576.00
This 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 our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
We anticipate the application window for this opening will close on: 03/29/2025
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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