Case Manager RN- Field

Job DescriptionNurse 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 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. Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.Schedule is Monday-Friday standard business hours (8:00-5:00pm). No weekends, no nights and no holidays.Travel region is southern WV and Charleston WV office. This is a full-time telework role, however 25% travel will be required for face to face assessments in Southern WV.Evaluation of Members:-Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member's needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.- Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. - Coordinates and implements assigned care plan activities and monitors care plan progress.-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 judgement 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-Uses a holistic approach assess the need for a referral to clinical resources for assistance in determine 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 care management process 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.Enhancement of Medical Appropriateness and Quality of Care:- Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes.- Identifies and escalates quality of care issues through established channels.-Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs.- Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote 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.Monitoring, Evaluation and Documentation of Care:- Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.Pay RangeThe typical pay range for this role is:Minimum: 55,300Maximum: 118,900Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required QualificationsRN with current unrestricted state licensure in the state of WV required3+ years of clinical practice experienceMust possess reliable transportation and a clean driving record for up to 25% travel for face to face visits with members in southern WV regionsWilling and able to travel within the counties of Boone, Greenbrier, Logan, McDowell, Mercer, Mingo, Monroe, Pocahontas, Raleigh, Summers or Wyoming or a bordering county.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred QualificationsFoster care or pediatric experience- DHHR experience- Case management and discharge planning experience- Managed care experienceBachelor's degree preferredEducationBachelor's degree in NursingBusiness OverviewBring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. 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.

Created: 2025-09-06