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Position Summary:

The Case Manager RN role is 100% remote work from home and candidates must live in the state of Pennsylvania and be licensed in the state of Pennsylvania.

• 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.
• 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.

• Must have an active, current and unrestricted RN licensure in the state of Pennsylvania and live in the state of Pennsylvania.
• Must be willing and able to obtain multiple state RN licensure after hire (expenses paid for by company)
• 2+ years of clinical experience as an RN- All clinical experience will be considered, such as Emergency Department, Home Health, Hospice, Operating Room, ICU, NICU, Telemetry, Medical / Surgical, Orthopedics, Long Term Care, and Infusion nursing.
• Must be willing and able to work Monday through Friday 9:00am - 5:30pm EST zone
• Must be willing and able to work occasional evening, weekend, and holiday shifts per the needs of the team.
• 3+ years' experience with Microsoft Office Suite

• Certified Case Manager (CCM) certification
• Case Management in an integrated model
• Discharge Planning experience
• Managed care experience