Pediatric Case Manager Rn

2 weeks ago

Tallahassee, United States CVS Health Full time

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

**Position Summary**

The Pediatric Care Manager RN will support a population of primarily medically complex pediatric members across the MMA and Florida Healthy Kids Medicaid lines of business with an emphasis on members receiving private duty nursing and nursing facility services. This role is remote, work from home, with field visits to members as needed and per contractual requirements. The CM RN utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wrap around services to promote effective utilization of available resources and optimal, cost-effective outcomes.

**Position Responsibilities**:

- Responsible for telephonic and face to face assessment, planning, implementing and coordinating care management activities with members to ensure that their medical and behavioral health needs are met and to enhance the member’s overall wellness.
- Develops a proactive course of action to address issues presented and facilitate short and long-term outcomes as well as identify opportunities to enhance a member’s overall health through integration.
- Through the use of clinical tools and information/data review, conducts comprehensive assessments of member’s needs and recommends an approach to case resolution by meeting needs in alignment with their benefit plan and available internal and external programs and services.
- Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and addresses complex health and social indicators which impact care planning and resolution of member issues.
- Completes assessments that take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality and the member’s restrictions and limitations.
- Analyzes utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
- 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 and services.
- Applies and/or interprets applicable criteria and clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards while assessing benefits and member’s needs to ensure appropriate administration of benefits.
- Serves as a single point of contact for members and assists members to remediate immediate and acute gaps in care and access.
- Using a holistic approach consults with manager, medical directors, and/or other physical/behavioral health support staff and providers to overcome barriers to meeting goals and objectives.
- Presents cases at case conferences/rounds to obtain multidisciplinary view in order to achieve optimal outcomes.
- Works collaboratively with the members’ interdisciplinary care team.
- 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 discern their health status and health needs based on key questions and conversation.
- 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.
- In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals.
- Utilizes care management processes in compliance with regulatory and company policies and procedures.
- Facilitates clinical hand offs during transitions of care.

**Required Qualifications**
- 3-5 years clinical practice experience with medically complex children required, e.g. hospital setting or alternative care setting

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