Job Description
Job Description
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. This is a work at home position and all training is virtual. Enhancement of Medical Appropriateness and Quality of Care:
- Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits.
- 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.
- 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.
-Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
- Utilizes case management processes in compliance with regulatory and company policies and procedures.
- Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
- Identifies and escalates member's needs appropriately following set guidelines and protocols.
Required Qualifications
- 5 years experience as a Registered Nurse with hospital experience and Case Management experience required (Nurse navigator/coordinator role).
- Multiple state RN licensure required upon hire.
- Need to actively reach out to members to collaborate/guide their care.
- Perform medical necessity reviews.
- Requires ability to document electronically using keyboard and multiple computer screens--free form text/good typing skills, experience with MCG, NCCN, Lexicomp a plus.
Preferred Qualifications
- Current or previous experience in Transplant, Oncology, Behavior Health, Substance Abuse, etc. preferred.
- Discharge planning experience from/to and transferring to lower levels of care.
- CCM and/or other URAC recognized accreditation 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 position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. This is a work at home position and all training is virtual. Enhancement of Medical Appropriateness and Quality of Care:
- Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits.
- 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.
- 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.
-Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
- Utilizes case management processes in compliance with regulatory and company policies and procedures.
- Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
- Identifies and escalates member's needs appropriately following set guidelines and protocols.
Required Qualifications
- 5 years experience as a Registered Nurse with hospital experience and Case Management experience required (Nurse navigator/coordinator role).
- Multiple state RN licensure required upon hire.
- Need to actively reach out to members to collaborate/guide their care.
- Perform medical necessity reviews.
- Requires ability to document electronically using keyboard and multiple computer screens--free form text/good typing skills, experience with MCG, NCCN, Lexicomp a plus.
Preferred Qualifications
- Current or previous experience in Transplant, Oncology, Behavior Health, Substance Abuse, etc. preferred.
- Discharge planning experience from/to and transferring to lower levels of care.
- CCM and/or other URAC recognized accreditation 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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