Nurse Case Manager/Assessor is responsible for telephonic and/or face to face assessing with members to evaluate the medical needs of the member to facilitate the member's overall wellness. Addressing requests for services such as adult medical daycare, pediatric medical daycare, personal care assistant, nursing facility stays. 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 through integration. 15 assessments minimum.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 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.Reviews prior claims to address potential impact on current case management and eligibility.Assessments include the member's level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining 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 case management processes 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.
This is an Exempt position.
2 years clinical practice experience required
RN with current unrestricted state licensure required in New Jersey
Travel required 75 - 100% in surrounding areas (Passaic County, Bergen County, Essex County, Hudson County)
Case Management in an integrated model preferred
Associate's degree or equivalent experience
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.