Case Manager Registered Nurse - Field

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Position Summary

The Complex Nurse Case Manager is responsible for assessing members through regular and consistent in person or telephonic contact to assess, plan, implement and coordinate all case management activities with members to evaluate the medical and psychosocial needs of the member to facilitate and support the member’s improved health. The Case Manager 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. Services strategies policies and programs are comprised of network management and clinical coverage policies.  

This is a field-based position that requires routine regional in-state travel 80-90% of the time; use of personal vehicle is required. Qualified candidates must have valid KY driver's license, proof of vehicle insurance, and reliable transportation. This position is assigned to the Cumberland Service Region. Qualified candidates must reside in one of the counties within the specified region. This includes one of the following: Green, Taylor, Adair, Cumberland, Casey, Russell, Wayne, Clinton, Pulaski, McCreary, Whitley, Laurel, Rockcastle, Jackson, Clay, Knox, Bell, or Harlan county.

Evaluation of Members: 

• Through the use of clinical assessment tools and evaluating information/data review, conducts a comprehensive and holistic 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. 
• Integrates assessment data from all care partners to holistically address all physical and behavioral health conditions including co-morbid and multiple diagnoses that impact functionality and member well-being. 
• Creates, monitors and revise member care plans to comprehensively address member biopsychosocial care needs. 
• Reviews prior claims to address potential impact on current case management and eligibility. 
• Assessments include the member’s functional capacity and related restrictions/limitations. 
• Using a holistic approach, assesses the need for a referral to additional clinical resources for assistance in determining functionality. 
• Consults with supervisor and other care partners to overcome 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 motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. 
• Helps member actively and knowledgably participate with their provider in healthcare decision-making. 

Required Qualifications

• 3+ years’ clinical practice experience including patient care coordination and health assessments.  

• RN with current unrestricted state licensure required. 

• 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)