The Medically Complex Nurse Case Manager is responsible for assessing members through regular and consistent in person or telephonic contact to assess, plan, implement and coordinate all case management activities with members to evaluate the medical and psychosocial needs of the member to facilitate and support the member's improved health. The Case Manager 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 member's overall wellness. Services strategies policies and programs are comprised of network management and clinical coverage policies. This is a field-based position that requires routine regional in-state travel 80-90% of the time; use of personal vehicle is required. Qualified candidates must have valid KY driver's license, proof of vehicle insurance, and reliable transportation. Travel to the Louisville office is also anticipated for meetings and training. This position is assigned to the Southern Bluegrass region (Boyle, Clark, Estill, Fayette, Garrard, Jessamine, Lincoln, Madison, Mercer, and Powell counties). Qualified candidates may reside in or adjacent to the assigned region.
• Through the use of clinical assessment tools and evaluating information/data review, conducts a comprehensive and holistic 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.
• Integrates assessment data from all care partners to holistically address all physical and behavioral health conditions including co-morbid and multiple diagnoses that impact functionality and member well-being.
• Creates, monitors and revise member care plans to comprehensively address member biopsychosocial care needs.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Assessments include the member's functional capacity and related restrictions/limitations.
• Using a holistic approach, assesses the need for a referral to additional clinical resources for assistance in determining functionality.
• Consults with supervisor and other care partners to overcome 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 motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
• Helps member actively and knowledgably participate with their provider in healthcare decision-making.
• 5 years' clinical practice experience.
• RN with current unrestricted state licensure required.
• Experience or detailed knowledge of the Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavioral Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, and evidence-based practices applicable to the Kentucky SKY populations, is required.
• Clinical experience and demonstrated knowledge of age appropriate developmental milestones.
• Clinical experience and understanding of complex medical conditions and treatment plans.
• Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
Field-based working environment with productivity and quality expectations.
Work requires the ability to perform close
inspection of handwritten and computer-generated documents as well as a PC monitor.
Sedentary work involving periods of sitting, talking, listening.
Work requires sitting for extended periods, talking on the telephone and typing on the computer.
Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.
Effective communication skills, both verbal and written.
Flexibility to work beyond core business hours of Monday-Friday, 8am-5pm, is required.
We are serving the needs of children and families that may require working after school, after work, etc.
• Case Management in an integrated model preferred.
• Bilingual preferred.
• Associate's degree required
• BSN preferred
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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