Case Manager Utilization Review Nurse Jobs in Decatur, IL

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselvesaccountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Position Summary

*Must reside in Illinois and possess IL RN License**

Program Overview

Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country.

Our Case Managers use a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.

Our Care Managers are frontline advocates for members who cannot advocate for themselves. They are responsible for 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 plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness.
Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits.
Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning.
Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality.
Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members.
Collaborates with supervisor and other key stakeholders in the member's healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences
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

A Brief Overview
Administers processes to coordinate and facilitate comprehensive care for individuals by assessing their needs, developing personalized care plans, and coordinating services across healthcare providers. Serves as advocate for patients, ensuring effective communication, resource utilization, and continuous monitoring of their progress to promote positive outcomes and enhance overall well-being.

What you will do

• Administers the care coordination plan to assess patient needs and ensure seamless transitions between different care settings.

• Analyzes complex patient data from medical history, diagnostic test results, and treatment plans, to understand the current health status of the patient.

• Applies in-depth knowledge of case management to organize patient files in an orderly manner for easy retrieval.

• Communicates through internal platforms to securely exchange messages, conduct video conferences, share files, and collaborate on patient care plans.

• Conducts routine utilization reviews to ensure patients have access to appropriate cost-effective care.

• Configures the case management system to organize cases dealing with disease management and utilization review; tracks patient progress and manages specific conditions.

• Coordinates analytics projects to enable case managers to analyze data and generate reports on key performance health indicators.

• Designs complex processes to coordinate discharge planning in a safe and timely transition from the hospital to home.

• Develops resource management to help case managers optimize healthcare with community resources.

Required Qualifications

This position will typically be a Work from Home role however candidate's must possess reliable transportation and be willing and able to travel up to 30% of the time if needed, in and around candidate's home location. Mileage is reimbursed per our company expense reimbursement policy

3-5 years of direct clinical practice experience e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility

Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually

Excellent analytical and problem-solving skills

Effective communications, organizational, and interpersonal skills

Ability to work independently

Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.

Efficient and Effective computer skills including navigating multiple systems and keyboarding

Preferred Qualifications

Case management and discharge planning experience

Managed care/utilization review experience

Crisis intervention skills

Certified Case Manager

Bilingual

Education and Certification Requirements

• Associate's Required, Bachelor's preferred

• Active and Unencumbered Registered Nurse License in Illinois

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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