clinical case manager

Healthnetwork Foundation

Clinical Manager: The Clinical Manager (CM) plays a vital role on our team, serving as a primary source of medical knowledge and guidance to ensure effective service for our members. In addition, the CM role facilitates ongoing education of the staff and ensures adherence to procedures, policies, best practices, and standards according to the mission of Healthnetwork Foundation. This role also includes managing medical cases for members (facilitation/referrals to hospital partners) and fundraising on behalf of the organization.Position requires:<ul><li>Comprehensive and diverse clinical knowledge</li><li>Excellent leadership abilities</li><li>Excellent interpersonal and communication skills</li><li>Ability to support or create a positive work environment</li><li>Ability to identify and solve problems</li><li>Adept at setting priorities and multitasking</li><li>Outstanding customer service and phone skills</li><li>Ability to work with confidential matters</li><li>Ability to work well in a team environment</li><li>Time management skills</li><li>Ability to recognize and pursue philanthropic opportunities</li></ul>Specific duties: include but are not limited to:<ul><li>Carries a manageable caseload that is primarily complex cases</li><li>Coordinates with leadership by streamlining requests and ensuring relevance</li><li>Contributes to updating policies or procedures as needed</li><li>Ongoing, periodic education to Medical Coordinator team</li><li>Serves as a resource to the MC core support function, offering clinical knowledge to ensure case efficiency</li><li>May be asked to represent HNW at select meetings locally and via travel to hospitals and member group locations</li></ul>Requirements:<ul><li>Degree in nursing or relevant clinical experience in a diverse setting</li><li>Experience working in a hospital or other medical facility</li><li>Maintains current licensure is encouraged</li></ul>Pay: From $90,000.00 per yearBenefits:<ul><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Parental leave</li><li>Retirement plan</li></ul>Work Location: In person

Clinical Case Manager

The Oaks at Radford Hills

<div>Description:

The Clinical Case Manager (CCM) is a licensed nurse responsible for coordinating and certifying the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) in compliance with federal and state regulations. The CCM collaborates with the interdisciplinary team to ensure accurate assessments, individualized care planning, PDPM compliance, and proper Medicare and Medicaid reimbursement while supporting quality, cost-effective resident care.
Essential Duties and Responsibilities:<ul><li>
Manage the RAI process from admission through discharge to ensure clinical compliance and appropriate Medicare, Medicaid, and Managed Care reimbursement.</li><li>
Complete and submit accurate, timely, and documentation-supported MDS assessments in accordance with the RAI 3.0 User&rsquo;s Manual.</li><li>
Review MDS analytics with the interdisciplinary team prior to submission; monitor validation reports and correct/re-submit rejected assessments within required timeframes.</li><li>
Conduct daily rounds on all Medicare Part A and Managed Care residents; identify changes in condition, initiate Significant Change MDS assessments, and update care plans with IDT input.</li><li>
Ensure completion of daily skilled documentation and nursing observation notes for all Medicare Part A and Managed Care residents.</li><li>
Assign appropriate ICD-10-CM codes to support skilled services.</li><li>
Coordinate physician certification and re-certification for Medicare Part A and Managed Care residents.</li><li>
Collaborate with the interdisciplinary team and Business Office Manager to support care planning, managed care authorizations, and clinical justifications.</li><li>
Attend required PPS, care plan, quality, and reimbursement meetings to identify changes impacting resident status or reimbursement.</li><li>
Issue Notices of Medicare Non-Coverage (NOMNC) as required.</li><li>
Ensure PASRR (PL1) compliance for all admissions per State of Texas guidelines.</li><li>
Provide training and support to nursing staff on ADLs and clinical case management responsibilities.</li><li>
Attend required training, meetings, and seminars.</li><li>
Performs other duties as assigned.</li></ul>
Requirements:
<ul><li>Must be a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in good standing and currently licensed by the state.</li><li>
Demonstrated proficiency in computer applications, including Microsoft Office and Outlook, with the ability to learn new systems.</li><li>
Minimum Data Set (MDS) and care planning experience preferred and working knowledge of Medicare and Medicaid programs preferred.</li><li>
Minimum of one (1) year of geriatric experience, preferably with supervisory experience.</li><li>
Must be able to interact positively with residents, families, and regulatory agencies, and work collaboratively with employees at all levels.</li><li>
Must be able to maintain consistent attendance and be willing to work long or irregular hours, often under pressure.</li></ul>
Physical Requirements:<ul><li>
Must comply with all local health regulations and successfully complete a post-offer health assessment.</li><li>
Must be able to perform the essential functions of the position with or without reasonable accommodation.</li><li>
Physical and Sensory Requirements (with or without the use of mechanical devices):</li><li>
Ability to read, write, and speak fluent English to communicate effectively with residents, families, staff, and community agencies.</li><li>
Ability to perform physical activities such as walking, reaching, bending, stretching, pulling, and lifting.</li><li>
Adequate fine and gross motor coordination to carry out required tasks.</li></ul>
Work Environment:<ul><li>
Long-term care facility setting.</li><li>
Exposure to residents with varying levels of care needs.</li><li>
May include evenings, weekends, holidays, and on-call shifts.</li></ul>
Core Competencies:<ul><li>
Resident-centered care</li><li>
Professionalism and ethical conduct</li><li>
Team collaboration</li><li>
Problem-solving</li><li>
Cultural sensitivity and respect</li></ul>
Employer Statement:
The facility is an equal opportunity employer. Duties and responsibilities may change based on business needs.</div>

Clinical Case Manager (CCM)

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
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&rsquo; 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&rsquo;s and family&rsquo;s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.
Fundamental Components
<ul><li>Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.</li></ul><ul><li>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.</li></ul><ul><li>Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician&rsquo;s office to provide ongoing case management services.</li></ul><ul><li>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&rsquo;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.</li></ul><ul><li>Communicates with member/client and other stakeholders as appropriate (e.g., medical</li></ul>
providers, attorneys, employers and insurance carriers) telephonically or in person.<ul><li>Prepares all required documentation of case work activities as appropriate.</li></ul><ul><li>Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes.</li></ul><ul><li>May make outreach to treating physician or specialists concerning course of care and treatment as appropriate.</li></ul>
&bull; Provides educational and prevention information for best medical outcomes. &bull; 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.<ul><li>Testifies as required to substantiate any relevant case work or reports.</li></ul>
&bull; Conducts an evaluation of members/clients&rsquo; needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data. &bull; Utilizes case management processes in compliance with regulatory and company policies and procedures.<ul><li>Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work.</li></ul><ul><li>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&rsquo;s/client&rsquo;s overall wellness through integration.</li></ul><ul><li>Monitors member/client progress toward desired outcomes through assessment and evaluation.</li></ul>
Required Qualifications:<ul><li>
Minimum 3-5 years clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac) with Medicare members.</li><li>
Minimum 2-3 years CM, discharge planning and/or home health care coordination experience</li><li>
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</li><li>
Excellent analytical and problem-solving skills</li><li>
Effective communications, organizational, and interpersonal skills.</li><li>
Ability to work independently (may require working from home).</li><li>
Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.</li><li>
Efficient and Effective computer skills including navigating multiple systems and keyboarding.</li></ul>
Preferred Qualifications:<ul><li>
3-5 years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility.</li><li>
Case management and discharge planning experience preferred</li><li>
Managed care/utilization review experience preferred</li><li>
Crisis intervention skills preferred</li></ul><div>
Education and Certification Requirements 
<ul><li>Behavioral Health clinical license in Illinois</li><li>Minimum of a Master's degree in Behavioral/Mental Health or related field</li></ul></div>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$66,575.00 - $142,576.00
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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 06/24/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Clinical Case Manager (Hybrid, IL)

University of Florida

<div><div>JOB NO:
<div>539492</div> 
WORK TYPE:
<div>Staff Full-Time</div> 
LOCATION:
<div>Main Campus (Gainesville, FL)</div> 
CATEGORIES:
<div>Health Care Administration/Support</div> 
DEPARTMENT:<div>
29180300 - MD-NEUROLOGY-MOVEMENT DISORDER</div></div> 
<div>
<div><div><div><div>CLASSIFICATION TITLE:</div>
<div>
Clinical Case Manager I</div> 
</div> 
<div><div>CLASSIFICATION MINIMUM REQUIREMENTS:</div> <div>Master's degree in an appropriate area; or a bachelor's degree in an appropriate area and two years of relevant experience.</div>
</div> 
<div><div>JOB DESCRIPTION:</div>
<div>
Join the University of Florida&rsquo;s Neurology team in the Movement Disorders Division as a Clinical Case Manager I, where you will make a meaningful impact on patients and families navigating complex neurological conditions. The Clinical Case Manager I independently provides casework services to patients and families as indicated to address the psychosocial aspects of care regarding adjustment to illness and treatment, as well as work collaboratively with interdisciplinary staff internal and external to the organization. The Clinical Case Manager I will participate in quality improvement and evaluation processes related to patient satisfaction and patient rights and serve as an information resource for the Fixel Institute of Neurological Diseases (FIND) in the Department of Neurology.

About this Role

Patient Care &amp; Navigation
<ul>
<li>Develop and implement individualized treatment plans aligned with patient needs</li>
<li>Provide patient navigation across care settings (inpatient, outpatient, home health, etc.)</li>
<li>Deliver education and support programming for patients and families</li>
<li>Assist with access to medications, transportation, and advance directives</li>
<li>Coordinate outreach with community resources, agencies, and advocacy groups</li>
<li>Program Coordination &amp; Reporting</li>
<li>Manage referrals for patients seen in the Memory Disorders Clinic and Neuromuscular program within the</li>
<li>Movement Disorders and Neurorestoration program</li>
<li>Monitor and respond to notifications from the Silver Alert Listserv in accordance with established guidelines</li>
<li>Conduct annual service provider and caregiver trainings related to memory care</li>
<li>Participate in Elder Affairs trainings and Memory Disorders quarterly meetings</li>
<li>Attend required clinics at FIND and support program initiatives</li>
<li>Track and report on specialized training programs developed or delivered</li>
<li>Submit required quarterly and annual reports for Elder Affairs</li>
<li>Maintain and log patient data in tracking systems for FIND</li>
</ul>
Crisis Intervention &amp; Documentation
<ul>
<li>Respond promptly to urgent patient and family needs, providing appropriate crisis intervention</li>
<li>Effectively manage high-pressure situations and problem-solve with limited information</li>
<li>Communicate critical issues to appropriate stakeholders in a timely manner</li>
<li>Identify priorities within complex situations and implement solutions efficiently</li>
<li>Document services in the electronic medical record (EMR) and maintain accurate records</li>
</ul>
Professional Engagement &amp; Representation
<ul>
<li>Attend required meetings, conferences, and trainings</li>
<li>Participate in committees and focus groups</li>
<li>Represent FIND at internal and external meetings and events</li>
<li>Complete all required reports and assignments within established timelines</li>
</ul>
Cross-Coverage Support
<ul>
<li>Provide backup support for case coordination across other divisions as needed</li> 
</ul>
We Offer Exceptional Benefits

Low-cost State Health Plans: Medical, Dental, and Vision Insurance 
Life and Disability Insurance 
Generous Retirement Options to secure your future 
Comprehensive Paid Time Off Packages: (includes over 10 paid holidays, as well as paid family, sick and vacation leave) 
Exceptional Personal and Professional Development Opportunities: Access to UF Training &amp; Organizational Development programs, leadership development, LinkedIn Learning, and more 
Tuition Assistance through the UF Employee Education Program 
Public Service Loan Forgiveness (PSLF) Eligible Employer 


About Gainesville, Florida

Home to the University of Florida, one of the nation's top public universities, Gainesville offers vibrant academic and healthcare communities alongside an affordable cost of living, no state income tax, and mild winters. Enjoy the outdoors with over 30 miles of bike trails, freshwater springs, and numerous water activities, plus easy access to beaches and world-class theme parks.

Gainesville combines historic charm with modern amenities, including a great school system, a lively downtown, and a thriving local culture with farmers' markets and craft breweries. Discover professional growth and quality of life in Gainesville&mdash;where community, innovation, and work-life balance meet!

For more information, check out: The Guide to Greater Gainesville and Explore Gainesville in 60 seconds</div> 
</div> 
<div><div>EXPECTED SALARY:</div>
<div>
$55,000 - $60,000 annually</div> 
</div> 
<div><div>MINIMUM QUALIFICATIONS:</div>
<div>
Master's degree in an appropriate area; or a bachelor's degree in an appropriate area and two years of relevant experience.</div> 
</div> 
<div><div>PREFERRED QUALIFICATIONS:</div>
<div>
The ideal candidate must possess:
<ul>
<li>Bachelor&rsquo;s degree in social work or a related field with one-year previous social service or casework
 
experience or appropriate college practicum.</li>
<li>Knowledge of the professional principles and skills used in the practice of social work</li>
<li>Professional empathy in dealing with families</li>
<li>Sense of professional identity while collaborating with co-workers</li>
<li>Awareness of community resources and programs for the disabled and elderly</li>
<li>Appropriate professional judgment, courtesy and tact.</li>
</ul>
</div></div> 
<div><div>SPECIAL INSTRUCTIONS TO APPLICANTS:</div>
<div>
To be considered, please upload the following:
<ul>
<li>Cover Letter</li>
<li>Resume</li>
<li>Contact information for three professional references</li>
</ul>
Application must be submitted by 11:55 p.m. (ET) of the posting end date.</div> 
</div> 
<div><div>HEALTH ASSESSMENT REQUIRED:</div> <div>Yes</div></div></div> 
</div>
</div><div>ADVERTISED:
<div>10 Apr 2026</div> Eastern Daylight Time 
APPLICATIONS CLOSE:
<div><div>24 Apr 2026</div></div>
Eastern Daylight Time</div></div>

Clinical Case Manager I- Neurology- Movement Disorders Division

Palm Medical Centers

<div>Palm Primary Care is a rapid growing company currently seeking an experienced Clinical Coordinator with leadership experience to join our team.
The Clinical Coordinator performs a variety of tasks and coordinates the plans of care for hospital and nursing home patients, from admission to discharge to ensure the continuation of care is provided effectively and efficiently.
Responsibilities include:<ul><li>
Admit new clients by reviewing records and applications; conduct orientations.</li><li>
Communicate the daily tracking of all hospital/nursing home admissions and discharge for both statistical and cost management purposes.</li><li>
Determine clients' requirements by completing intake interviews; Determine need for therapeutic medical, psycho-social, and psychiatric evaluations, review therapist evaluations, treatment objectives, and plans.</li><li>
Establish treatment programs by setting schedules and routines; coordinate services being provided; arrange resources- including transportation and escort.</li><li>
Monitor cases by verifying clients' attendance; observe and evaluate treatments and responses; advocate for needed services and entitlements; obtain additional resources; ability to intervene in moments of crises by providing personal support.</li><li>
Maintain clients' records by reviewing case notes, logging events and progress.</li><li>
Communicates with PPC managers on members discharged from inpatient facilities to assure appropriate medical care follow up</li><li>
Obtain weekly update on all nursing home patients</li><li>
Communicate potential catastrophic and stop loss patients</li><li>
Identify patients related to possible subrogation and/or cost allocations</li><li>
Coordinate the transfers of patients as instructed by the Medical Director or PCP.</li><li>
Arrange direct admissions to hospitals and placement in nursing homes</li><li>
Assist PCP in placing patients at SNF</li><li>
Monitor length of stay (LOS) for both hospital and nursing home patients and make necessary discharge arrangements</li><li>
Communicate clients' progress by conducting weekly interdisciplinary meetings and evaluations, disseminating results and obstacles to therapeutic team and family, identify treatment influences.</li><li>
Improve staff competence by providing educational resources; balancing work requirements with learning opportunities; evaluating the application of learning to changes in treatment results.</li><li>
Improve treatment results by studying, evaluating, and re-designing processes, implementing changes, rewriting policies and procedures.</li><li>
Improve financial status by analyzing results, monitoring variances, identifying trends, and recommending actions to management.</li></ul>
Requirements:<ul><li>
Proven working experience in case management, mental health care manager or a related job experience</li><li>
Excellent knowledge of case management principles, management and reimbursement</li><li>
Previous experience with psychological aspects of care</li><li>
Effective communication skills</li><li>
Excellent organizational and time management skills</li><li>
Familiarity with professional and technical emerging knowledge</li><li>
Problem solving skills and ability to multi-task</li><li>
Compassionate with teamwork skills</li><li>
Knowledge of terminology CPT codes and ICD 10</li><li>
Bilingual preferred</li><li>
Knowledge of InterQual or Milliman Care Guidelines preferred</li></ul>
Minimum Qualifications: Minimum 3 years of Clinical Coordinator experience.
Job Type: Full-time
Salary: negotiable based on experience
Benefits:<ul><li>
401(k)</li><li>
Dental insurance</li><li>
Employee assistance program</li><li>
Flexible spending account</li><li>
Health insurance</li><li>
Life insurance</li><li>
Paid time off</li><li>
Vision insurance</li></ul>
Schedule:<ul><li>
Day shift</li><li>
Monday to Friday</li></ul>
Experience:<ul><li>
Case management: 3 years (Required)</li></ul>
Work Location: Hybrid
lXWWrCfQnb</div>

Clinical Coordinator / Case Manager

AmeriHealth Caritas

<div>For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We are looking for the next generation of health care leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
The Clinical Case Manager assists members who are eligible for LTSS in obtaining the services they need as required by DSHP Plus LTSS in New Castle county. He or she contributes to the LTSS case management process by performing telephonic and/or face-to-face assessments for the identification, evaluation, coordination and management of member&rsquo;s needs, including physical health, behavioral health, social services and long term services and supports. This position is also responsible for completing Level of Care Redeterminations for home and community based members annually. This requires clinical review when evaluating the need for a member to remain in the program. The Clinical Case Manager will also provide clinical support to his/her non-licensed counterparts and may act as a secondary case manager when a member is experiencing an acute episode.<ul><li>
Coordination of care for medically complex LTSS Members receiving private duty nursing (PDN)</li><li>
Performs follow-up on outstanding items of need and maintains a calendar or PDN Coverage.</li><li>
Establish communication method to effectively communicate with multiplePDN agencies and member/member representative.</li><li>
Coordinates and collaborates with prior authorization team to make sure all necessary precertifications for required services are submitted for review. Assists in obtaining the Letter of Medical Necessity (LOMN) as needed</li><li>
Coordinate with provider network team in the utilization of non-contracted providers or facilities as necessary following the single case agreement (SCA) process</li><li>
Conducts reevaluation of level of care annually or more frequently as needed in accordance with DSHP Plan Plus LTSS requirements.</li><li>
Provides clinical support to non-licensed case managers as needed.</li><li>
Conduct condition specific assessments with members with chronic conditions. Provide education and routine follow-up with member.</li><li>
Perform initial clinical assessment of new members, develop care plan, and initiate services.</li><li>
Facilitate person-centered planning team meetings to coordinate care and services. Identify, coordinate, and assist participants in gaining access to needed LTSS and other Covered Services, as well as non-covered medical, social, housing, educational, and other services and supports.</li><li>
Provides information to participants and conducts monitoring of authorized services and supports for Participants.</li><li>
Informs participants about available LTSS required needs assessments, the care plan process, service alternatives and service delivery options.</li><li>
Informs participants of their rights and responsibilities as well as assists with the complaint, grievance, and DHS Fair Hearing process.</li><li>
Collects additional necessary information, including participant preferences, strengths, and goals to inform the development of the Plan of Care.</li><li>
Conducts comprehensive needs assessments annually or more frequently as needed in accordance with requirements.</li><li>
Review and acting upon worklists in Jiva, including monitoring of new members</li><li>
Authorize urgent services when needed</li><li>
Monitoring critical incident reporting/documentation, recommending/taking action w/ other corporate entities as required</li><li>
Liaison activities with Physical health Care Coordination program</li><li>
Working with LTSS and DSNP members to complete comprehensive assessments, care plans, medication reconciliation, monitoring follow-up and progress, and assisting with discharge planning/transitions of care.</li></ul>
Education/Experience:<ul><li>
Delaware licensed RN required.</li><li>
Ability to travel throughout entire state of DE.</li><li>
Valid driver&rsquo;s license required</li><li>
Knowledge of the home and community-based service system and how to access and arrange for services</li><li>
Experience conducting LTSS needs assessments and monitoring LTSS delivery</li><li>
Ability to provide informed advocacy</li><li>
Ability to interact with members face to face</li><li>
Ability to interact with health care professionals in a professional manner</li><li>
Ability to travel up to 75%</li><li>
Duties may include case management responsibilities based on business needs. This role is also a part of the contingency plan, where a caseload may be assigned in the event of a staffing need</li></ul>
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.</div>

Clinical Case Manager DE Long Term Services & Support-Private Duty Nursing

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary 
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. 
Position Summary/Mission 
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. 
Fundamental Components &amp; Physical Requirements
<h3 class="jobSectionHeader">(Include but are not limited to)</h3> 
Assessment of Members<ul><li>
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member&rsquo;s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member&rsquo;s benefit plan and available internal and external programs/services.- Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.</li><li>
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.</li></ul>
Enhancement of Medical Appropriateness and Quality of Care<ul><li>
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member&rsquo;s needs to ensure appropriate administration of benefits</li><li>
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes</li><li>
Identifies and escalates quality of care issues through established channels</li><li>
Ability to speak to medical and behavioral health professionals to influence appropriate member care.</li><li>
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health</li><li>
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.</li><li>
Helps member actively and knowledgably participate with their provider in healthcare decision-making</li><li>
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.</li></ul>
Monitoring, Evaluation and Documentation of Care<ul><li>
In collaboration with the member and their care team develops and monitors established plans of care to meet the member&rsquo;s goals</li><li>
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.</li></ul> 
Required Qualifications<ul><li>
Candidate must reside in Illinois</li><li>
Candidate must possess reliable transportation and be willing and able to travel up to 25% of the time in and around candidates home locations (Mileage is reimbursed per our company expense reimbursement policy)</li><li>
Candidate must have active and unrestricted Licensed Clinical Social Worker (LCSW)/ Licensed Clinical Professional Counselor (LCPC) in Illinois</li><li>
3-5 years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
</li><li>Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually</li><li>
Excellent analytical and problem-solving skills</li><li>
Effective communications, organizational, and interpersonal skills.</li><li>
Ability to work independently</li><li>
Effective computer skills including navigating multiple systems and keyboarding</li><li>
Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications</li></ul> 
Preferred Qualifications<ul><li>
Case management and discharge planning experience</li><li>
Managed care/utilization review experience</li><li>
Crisis intervention skills</li></ul> 
Education<ul><li>
Master's Degree in Behavioral/Mental Health or related field (REQUIRED)</li></ul>
License<ul><li>
Active and unrestricted Licensed Clinical Social Worker (LCSW)/ Licensed Clinical Professional Counselor (LCPC) in Illinois</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$66,575.00 - $142,576.00
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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 06/30/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Behavioral Health Clinical Case Manager - LCPC/LCSW - Illinois

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