Case Manager RN

CVS Pharmacy

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Posted Date 7/27/2020

At Aetna Better Health of Texas, we are committed to helping people on their path to better health. By taking a total and connected approach to health, we guide and support our members so they can get more out of life, every day. We are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of Texas STAR Kids members. We value diversity and are dedicated to helping you achieve your career goals.

The Transition Coordinator RN 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. 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. Services strategies policies and programs are comprised of network management and clinical coverage policies.

This position requires routine travel in the Dallas service area, 70-80% of the time. Some travel to the Dallas office, support location, may also be required. Use of personal vehicle when traveling in the field; must have active and valid TX driver's license, reliable transportation and vehicle insurance. Business mileage is eligible for reimbursement, in accordance with travel policy guidelines. Candidates may reside in any of these or adjacent counties: Collin, Dallas, Ellis, Hurt, Kaufman, Navarro, and Rockwall.

Fundamental Components
  • 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.
  • Works collaboratively with member and their social supports to develop and implement a service plan specific to transitioning members from pediatric to adult care holistically.
  • Ensures successful transition from pediatric to adult care and MCO.

Background Experience
  • RUG certified RN; or ability to complete RUG certification within 60 days of start date is required.
  • 5 years clinical practice experience RN with current unrestricted state licensure required.
  • Case Management in an integrated model preferred.
  • Pediatric/Adolescent experience preferred
  • Bilingual preferred.

Additional Job Details:
  • Typical office working environment with productivity and quality expectations
  • Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
  • 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
  • Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel. Strong keyboard and mouse skills required.
  • Effective communication skills, both verbal and written.

Additional Job Information
TX STAR Kids expansion; confirm all posting content with hiring manager. Target start date August 2020, target salary max. $81,900K DOE. All finalist candidates and offers must be reviewed/approved by Barb Clopton prior to offer extension. Confirm DEPT/CC prior to offer extension. Additional paid advertising requests must be approved centrally by Barb Clopton prior to placement. COBRA assistance may be available. We anticipate interest from Dallas Childrens Medical Center (DCMC) staff, the exiting MCO. Please forward all DCMC resumes ASAP; these candidates are preferred as they are currently servicing the contract and TSK members and this will promote continuity of continued care.

Associate's degree or equivalent experience

Percent of Travel Required
75 - 100%

Business Overview
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.

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