CVS Health Transplant Case Manager RN Registered Nurse in Tempe, Arizona
Transplant Nurse Case Manager (Txp CM) conducts review and determination of medical necessity of prior authorization requests related to the transplant services. Txp CM is responsible for care coordination between the member, transplant center, PCP, specialists, pharmacy, & etc. Txp CM gathers documentation and presents written case summary to the health plan's MD for the recommendations. Other responsibilities include telephonically 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 outcome.
Must reside in state of Arizona. Quarterly meetings in the office.
Schedule is Monday-Friday standard business hours. No nights, and no weekends. Few holidays!
Through the use of clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility. 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. 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.
Utilization Management or Case Management in an integrated healthcare model/managed care setting required
Minimum of 5 years clinical practice experience
Transplant experience is preferred
Knowledge of Medicaid and Medicare preferred
RN with current unrestricted state of Arizona licensure required.
Additional Job Information
Typical office working environment with productivity and quality expectations Work requires the ability to perform close inspection of hand 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 Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written.
Bachelor's degree or equivalent experience
Percent of Travel Required
0 - 10%
Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
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