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Position Summary:

The 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 Jefferson Region.

Flexibility to work beyond core business hours of Monday-Friday, 8am-5pm, is required.

Evaluation of Members:

• 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.

• Field-based working environment with productivity and quality expectations.

• Work requires the ability to perform close inspection of handwritten and computer-generate

• 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

Required Qualifications:

• Qualified candidates may reside in Jefferson Region

• 3+ years’ clinical practice experience as RN

• Current unrestricted RN licensure in KY

• Flexibility to work beyond core business hours of Monday-Friday, 8am-5pm, (We are serving the needs of children and families that may require working after school, after work, etc.)

• Willing and able to travel for face-to-face visits with members 80-90% of their time in Jefferson Region

• Must have valid KY driver's license, proof of vehicle insurance, and reliable transportation. Mileage is reimbursed per our company expense reimbursement policy

Preferred Qualifications:

• 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

• Pediatric experience

• Case Management experience in an integrated model

• Bilingual

• Computer literacy and demonstrated proficiency to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.

• Effective communication skills, both verbal and written

.

Education

• Associate’s degree in Nursing or Diploma RN required

• BSN preferred

Pay Range

The typical pay range for this role is:

$54,095.60 - $116,760.80

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 01/04/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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. CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through [email protected] If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.