This is a full time remote teleworker position in Virginia supporting the Maternity / NICU team. Travel is required 25-40% of the time in the Southwest Region of VA. Qualified candidates must reside in one of the following counties: (Bland, Galax, Scott, Bristol, Grayson, Smyth, Buchanan, Lee, Tazewell, Carroll, Norton, Washington, Dickenson, Russell, Wise). Hours for this position are Monday-Friday 8:00am - 5:00pm EST.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. 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.• Typical office working environment with productivity and quality expectations• Work requires the ability to perform close inspection offhand written 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• Effective communication skills, both verbal and written.
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
• Registered Nurse with current unrestricted Virginia (VA) license or VA ”multi-state privilege” license• 5+ years of clinical practice experience• 1+ year(s) of clinical nursing experience with medically complex members• Must reside in the Southwest region of VA • Must possess reliable transportation and must be willing and able to travel in the assigned region 25-40% of the time. Mileage is reimbursed per our company expense reimbursement policy • 2+ years of demonstrated experience with personal computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint).
• Experience working with maternity, pediatrics, or NICU member populations• Case management experience in an integrated model • Case Management (CCM) Certification
• Associate's Degree in Nursing or Nursing Diploma required• BSN degree is preferred
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