SKY Complex Care Manager- Case Manager RN- Field (Northern Bluegrass Region)

Complex Nurse Case Manager

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As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

The Complex Nurse Case Manager is responsible for assessing members through regular and consistent in-person or telephonic contact to assess, plan, implement and coordinate all case management activities with members to evaluate the medical and psychosocial needs of the member to facilitate and support the member's improved health. The Case Manager 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. Services strategies policies and programs are comprised of network management and clinical coverage policies.

This is a field-based position that requires routine regional in-state travel 80-90% of the time; use of personal vehicle is required. Qualified candidates must have valid KY driver's license, proof of vehicle insurance, and reliable transportation. Travel to the Louisville office is also anticipated for meetings and training. This position is assigned to the Northern Bluegrass Region. Qualified candidates must reside in one of the counties within the specified region (Boone, Bourbon, Campbell, Carroll, Gallatin, Grant, Harrison, Kenton, Nichols, Owen, Pendleton, and Scott).

Evaluation of Members:

Through the use of clinical assessment tools and evaluating information/data review, conducts a comprehensive and holistic 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. Integrates assessment data from all care partners to holistically address all physical and behavioral health conditions including co-morbid and multiple diagnoses that impact functionality and member well-being. Creates, monitors and revise member care plans to comprehensively address member biopsychosocial care needs. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member's functional capacity and related restrictions/limitations. Using a holistic approach, assesses the need for a referral to additional clinical resources for assistance in determining functionality. Consults with supervisor and other care partners to overcome 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 motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. Helps member actively and knowledgably participate with their provider in healthcare decision-making.

Required Qualifications

• 3+ years' clinical practice experience including patient care coordination and health assessments.
• RN with current unrestricted state licensure required.
• 2+ years' experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
• Must possess reliable transportation and be willing and able to travel in-state up to 80-90% of the time. Mileage is reimbursed per our company expense reimbursement policy.
• Flexibility to work beyond core business hours of Monday-Friday, 8am-5pm, is required.
• Candidate must reside in the specific counties of the services region; (Boone, Bourbon, Campbell, Carroll, Gallatin, Grant, Harrison, Kenton, Nichols, Owen, Pendleton, and Scott) counties in KY.

Preferred Qualifications

• Experience or detailed knowledge of the Foster Care and juvenile justice systems, Adoption Assistance, the delivery of Behavioral Health Services, Trauma-informed Care, ACEs, Crisis Intervention services, and evidence-based practices applicable to the Kentucky SKY populations, is required.
• Clinical experience and demonstrated knowledge of age appropriate developmental milestones.
• Clinical experience and understanding of complex medical conditions and treatment plans.
• Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
• Field-based working environment with productivity and quality expectations.
• Work requires the ability to perform close inspection of handwritten 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.
• Case Management in an integrated model preferred.
• Discharge Planning Experience.
• Motivational Interviewing skills
• Managed Care/Utilization Review Experience
• Bilingual preferred.
• BSN preferred

Education

Minimum of Associate's Degree in Nursing required; Bachelor's Degree in Nursing is preferred

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,095.00 - $116,760.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

We anticipate the application window for this opening will close on: 11/30/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.