Case Manager RN - Field Northern Region WV

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Position Summary

This is a full-time field teleworker position that requires travel 50% of the time or more, in the following counties: Barbour, Brooke, Doddridge, Hancock, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants, Ritchie, Taylor, Tyler, Upshur, Wetzel. Field based travel locations may include member homes, residential treatment facilities, group homes, shelters, and detention facilities.  Qualified candidates must reside in the region, in one of the following counties: Barbour, Brooke, Doddridge, Hancock, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants, Ritchie, Taylor, Tyler, Upshur, Wetzel or that reside in the state of Maryland within 50 commutable miles of the Northern region.

Schedule is Monday – Friday, 8am-5pm, standard business hours. No nights, weekends, or holidays. A flexible work schedule may be available after 6 months of service and with demonstrated performance and attendance.

The Case Manager RN (CM 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 is heavy community-based with some onsite presence at Department of Health and Human Resources (DHHR) offices. 

Fundamental Components:

• 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.

• Effective communication skills, both verbal and written.

• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.

Required Qualifications

• Must reside in the region, in one of the following counties: Barbour, Brooke, Doddridge, Hancock, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants, Ritchie, Taylor, Tyler, Upshur, Wetzel or reside in the state of Maryland within 50 commutable miles of the Northern region.
• Current unrestricted West Virginia (WV) RN license or compact RN 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 within the Northern region of WV. Mileage is reimbursed per our company expense reimbursement policy

Preferred Qualifications

• Pediatric or adolescent experience
• Medicaid e