Remote Utilization Review Rn Jobs in McHenry, IL

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Position Summary

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.

Family Summary/Mission

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements, and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

Position Summary/Mission

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.

Fundamental Components & Physical Requirements

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

Remote Work Expectations

• This is a remote-hybrid role; candidates must have a dedicated workspace free of interruptions

• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Required Qualifications

• Must reside in Illinois

• 3-5 years clinical practical experience

• 2-3 years CM, discharge planning and/or home health care coordination experience

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

• Must possess reliable transportation and be willing and able to travel up to 50% in Cook County and surrounding areas. Mileage is reimbursed per our company expense reimbursement policy

• 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

• Certified Case Manager

• Bilingual

Education

Master's Degree in Behavioral/Mental Health or related field

License:

LCSW or LCPC in the state of 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.