Case Manager, RN – Field

• Conducts face to face member visits
• Using 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.
• Assesses 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.
• 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.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.

Requirements

• Registered Nurse with current unrestricted West Virginia (WV) license or Registered Nurse with current unrestricted WV or ”multi-state privilege” license
• 5+ years’ clinical practice experience
• 2+ years’ experience with personal computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint, Teams)
• Must possess reliable transportation and be willing and able to travel in the assigned region 50% or more, of the time.

Core Competencies

Demonstrates expertise in clinical assessment and case management, utilizing a holistic approach to evaluate member needs and facilitate transitions to appropriate programs. Proficient in regulatory compliance and effective communication to enhance member engagement and care planning.