Case Manager, Registered Nurse (Remote)

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

Help us elevate our patient care to a whole new level! Join our team as an industry leader in serving our members by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members. Community Care is a member centric, team-delivered, community-based care management model that joins members where they are. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country.

As a case manager, you will coordinate and facilitate comprehensive care for individuals by assessing their needs, developing personalized care plans, and coordinating services across healthcare providers. Serves as advocate for patients, ensuring effective communication, resource utilization, and continuous monitoring of their progress to promote positive outcomes and enhance overall well-being.

Additional responsibilities to include but not limited to the following:

• Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.
• Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.
• Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services.
• Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate.
• Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.
• Prepares all required documentation of case work activities as appropriate.
• Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.
• May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.
• Provides educational and prevention information for best medical outcomes.
• Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources.
• Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member’s/client’s overall wellness through integration.
• Monitors member/client progress toward desired outcomes through assessment and evaluation.

Required Qualifications

• Candidate preferably resides in Michigan
• Candidate must have active and unrestricted RN licensure in Michigan
• 3+ years of clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac, Home Health) with Medicare members
• 2+ years of case management, discharge planning and/or home health care coordination experience
• Proficiency with standard corporate software applications, including Microsoft Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications
• Able to work in a fast paced high volume environment and utilize time management and prioritization skills
• Efficient and effective computer skills including navigating multiple systems and keyboarding
• Working knowledge of problem solving and decision making skills
• Working knowledge of medical terminology
• Working knowledge of digital literacy skills
• Ability to deal tactfully with customers and community

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