Job Description
Job Description
This role is fully remote. Candidates should reside within a commutable distance to San Antonio, TX. Travel to the
San Antonio office occasionally will be required once
COVID restrictions are lifted.
Standard business hours are required Monday-Friday 8am-5pm with flexibility to rotate to 7pm CST on occasion when required to meet business needs.
Nurse Case Manager is responsible for telephonically
and/or face to face assessing, planning, implementing and
coordinating all case management activities with members
to evaluate the medical needs of the member to facilitate
the members overall wellness. Develops a proactive
course of action to address issues presented to enhance
the short and longterm outcomes as well as opportunities
to enhance a members overall wellness through
integration. Services strategies policies and programs are
comprised of network management and clinical coverage
policies.
- Through the use of clinical tools and information/data
review, conducts an evaluation of member's needs and
benefit plan eligibility and facilitates integrative functions as
well as smooth transition to Aetna programs and plans.
- 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.
- Reviews prior claims to address potential impact on
current case management and eligibility.
- Assessments include the members level of work capacity
and related restrictions/limitations.
- Using a holistic approach assess the need for a referral
to clinical resources for assistance in determining
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.
- Utilizes case management processes in compliance with
regulatory and
company policies and procedures.
- Utilizes interviewing skills to ensure maximum member
engagement and discern their health status and health
needs based on key questions and conversation.
Required Qualifications
-RN with current unrestricted state licensure required
-Willingness to obtain additional state licenses will be
required upon hire
- 3+ years clinical practice experience required
- Strong computer skills are required
Preferred Qualifications
- Case Management in an integrated model preferred
- Bilingual preferred
Education
Bachelor's degree or equivalent experience
Business Overview
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.
This role is fully remote. Candidates should reside within a commutable distance to San Antonio, TX. Travel to the
San Antonio office occasionally will be required once
COVID restrictions are lifted.
Standard business hours are required Monday-Friday 8am-5pm with flexibility to rotate to 7pm CST on occasion when required to meet business needs.
Nurse Case Manager is responsible for telephonically
and/or face to face assessing, planning, implementing and
coordinating all case management activities with members
to evaluate the medical needs of the member to facilitate
the members overall wellness. Develops a proactive
course of action to address issues presented to enhance
the short and longterm outcomes as well as opportunities
to enhance a members overall wellness through
integration. Services strategies policies and programs are
comprised of network management and clinical coverage
policies.
- Through the use of clinical tools and information/data
review, conducts an evaluation of member's needs and
benefit plan eligibility and facilitates integrative functions as
well as smooth transition to Aetna programs and plans.
- 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.
- Reviews prior claims to address potential impact on
current case management and eligibility.
- Assessments include the members level of work capacity
and related restrictions/limitations.
- Using a holistic approach assess the need for a referral
to clinical resources for assistance in determining
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.
- Utilizes case management processes in compliance with
regulatory and
company policies and procedures.
- Utilizes interviewing skills to ensure maximum member
engagement and discern their health status and health
needs based on key questions and conversation.
Required Qualifications
-RN with current unrestricted state licensure required
-Willingness to obtain additional state licenses will be
required upon hire
- 3+ years clinical practice experience required
- Strong computer skills are required
Preferred Qualifications
- Case Management in an integrated model preferred
- Bilingual preferred
Education
Bachelor's degree or equivalent experience
Business Overview
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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