Case Manager RN

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
The RN Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

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 Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits. Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Standard business hours: Monday - Friday 8:00 am - 5:00 pm EST.

Candidates will need a quiet, dedicated work space with no distractions. This role will require that the candidate be hard wired into the modem. May spend up to 20% of time in the community for field visits.

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.
• Majority of time is spent on telephonic outreach and documentation in a clinical case management platform.

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 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.

Required Qualifications
Must have an active and unrestricted RN license in the state of Michigan.

Candidate MUST reside in one of these counties: Berrien, Van Buren, Cass, Kalamazoo, St. Joseph, Calhoun, Branch, Jackson, Hillsdale, Livingston, Washtenaw, Lenawee, Monroe, Oakland, Macomb, Wayne, Clinton, Eaton, or Ingham

Preferred Qualifications
-3 years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.

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