at CVS Health in Chicago, Illinois, United States
Job Description
Job Description
This will be a full-time telework role. However, must be willing and able to travel up to 25% of their time to meet members within Cook County IL and as needed office based meetings in Downers Grove IL once COVID restrictions are lifted.
Nurse 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 member’s overall wellness.
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.
Fundamental Components & Assessment of Members: Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services.
– Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
– Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Enhancement of Medical Appropriateness and Quality of Care:
– Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
– Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
– Identifies and escalates quality of care issues through established channels
– Ability to speak to medical and behavioral health professionals to influence appropriate member care.
– Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes 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 – Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
Monitoring, Evaluation and Documentation of Care: In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals.
– Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Work hours are 8:00am -5pm CST
