Position Summary
Help us elevate our patient care to a whole new level! Join our Community Care team as an industry leader in serving our members by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Community Care members. Community Care is a member centric, team-delivered, community-based care management model that joins members where they are. 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
Community Care Case Manager 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
- Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.
- Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.
- Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician's office to provide ongoing case management services.
- Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client's appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate.
- Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person.
- Prepares all required documentation of case work activities as appropriate.
- Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.
- May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.
- Provides educational and prevention information for best medical outcomes.
- Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources.
- Testifies as required to substantiate any relevant case work or reports.
- Conducts an evaluation of members/clients' needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data.
- Utilizes case management processes in compliance with regulatory and company policies and procedures.
- Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.
- 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/client's overall wellness through integration.
- Monitors member/client progress toward desired outcomes through assessment and evaluation.
Required Qualifications
- Candidate must reside in Florida
- Candidate must have active and unrestricted Compact Registered Nurse (RN) License in Florida
- 3+ years clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac) with Medicare members
- 2+ years case management, discharge planning and/or home health care coordination experience
Preferred Qualifications
- Ability to occasionally travel within a designated geographic area for in-person case management activities as directed by leadership and/or as business needs arise
- Excellent analytical and problem-solving skills
- Effective communications, organizational, and interpersonal skills
- Ability to work independently (may require working from home).
- 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
- Certified Case Manager
- Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM)
Education
- Associate's Degree in Nursing with equivalent experience or Nursing Diploma (REQUIRED)
- Bachelor's Degree (PREFERRED)
License
- Active and unrestricted Compact Registered Nurse (RN) License in Florida
Work from Home Requirements
- You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
- A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
- Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
- The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
- If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
Technical and Logistical Requirements
- Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
- Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
- Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
- Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
- Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
- Future Growth: Openness to learning new skills in the future as the workplace environment evolves
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is
$60,522.00 - $129,615.00