This is a remote work from home role anywhere in the US with virtual training.
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. 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.
-Need to actively reach out to members to collaborate/guide their care.
-Perform medical necessity reviews
-Will need to obtain a multi state license upon hire.
- Monday - Friday 8:30-5:00pm
The typical pay range for this role is:
Please 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.
-5+ years experience as a Registered Nurse; preferably in a specialty.
- Must hold an active/unrestricted RN licensure in the state that you reside.
-1+ year experience documenting electronically using keyboard and multiple computer screens--free form text/good typing skills.
-1+ years current or previous experience in one of the following: Oncology, Behavioral Health/Substance Abuse, or Transplant.
COVID-19 Vaccination Requirement
CVS 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.
-1+ years Case Management experience (Nurse navigator/coordinator role).
- CCM and/or other URAC recognized accreditation preferred
- 1+ years Experience with MCG, NCCN, Lexicomp a plus.
- 1+ years of discharge planning, nurse navigator or nurse care coordinator with experience transferring patients to lower/higher levels of care.
Bring 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.