Case Manager - Registered Nurse

Position Overview

• Location Type: Fully Remote
• Job Type: Full time
• Salary: $54,095.00 - $116,760.00

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. 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.

This Case Manager - Registered Nurse (RN) position is with Aetna’s National Medical Excellence (NME) team and is a fully remote position. Candidates from any state are welcome to apply, however, preference is for candidates in compact Registered Nurse (RN) states. This role is a blended role doing both Case Management and Utilization Management. The RN Case Manager is responsible for telephonically and/or face to face 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.

Responsibilities

• 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 consider 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.
• Assess 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.

Requirements

• Active, current, and unrestricted compact Registered Nurse (RN) licensure in the state of residence.
• 5 years clinical practice experience as a Registered Nurse (RN).
• 2+ years’ experience in critical care.
• 6+ months case management or utilization management experience.
• Must be able to work Monday - Friday 8 AM to 5 PM in the time zone of residence (currently no nights, weekends, and holidays; however, this is subject to change based on business needs).
• Must be able to obtain multi-state Registered Nurse (RN) licensures.

Preferred Qualifications

• Case Management Certification
• Transplant experience

Education

• Associate's Degree in Nursing (REQUIRED)
• Bachelor's Degree in Nursing (PREFERRED)

License

• Must have an active, current, and unrestricted compact Registered Nurse (RN) licensure in the state of residence.

Work Schedule

• Anticipated Weekly Hours: 40
• Time Type: Full time