Job Description
Job Description
Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.
Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and
strategies, policies and programs are comprised of network management, clinical coverage, and policies.
Nurse Case Manager is responsible for telephonic 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 long-term 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
5 years clinical practice experience required
RN with current unrestricted state licensure required.
50-75% travel required in Kansas Metro area and surrounding areas: Johnson, Wyandotte, Leavenworth, Douglas, Miami, Osage, Linn, and Anderson
Preferred Qualifications
Case Management in an integrated model preferred.
1+ years experience Home and Community based Services experience in Technology Assisted (TA) waiver preferred
Education
Associates or Bachelors degree preferred
RN with current unrestricted state licensure required.
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.
Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.
Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and
strategies, policies and programs are comprised of network management, clinical coverage, and policies.
Nurse Case Manager is responsible for telephonic 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 long-term 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
5 years clinical practice experience required
RN with current unrestricted state licensure required.
50-75% travel required in Kansas Metro area and surrounding areas: Johnson, Wyandotte, Leavenworth, Douglas, Miami, Osage, Linn, and Anderson
Preferred Qualifications
Case Management in an integrated model preferred.
1+ years experience Home and Community based Services experience in Technology Assisted (TA) waiver preferred
Education
Associates or Bachelors degree preferred
RN with current unrestricted state licensure required.
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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