Case Manager, Registered Nurse - Fully Remote at CVS Health

United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting
Active, unrestricted Registered Nurse license in state of residence, willingness to receive multi-state/compact privileges, and ability to be licensed in all non-compact states
1+ years’ experience documenting electronically using a keyboard
1+ years’ current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse, or Maternity/Obstetrics
Diploma or Associates Degree in Nursing required (BSN preferred)

Responsibilities

Work telephonically as a case manager with patients and their care team for fully and/or self-insured clients
Apply and/or interpret applicable criteria, clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
Apply clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators impacting care planning and resolution of member issues
Conduct assessments utilizing information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality
Consult with supervisor and others to overcome barriers in meeting goals and objectives, and present cases at case conferences for multidisciplinary focus to benefit overall claim management
Use a holistic approach to consult with clinical colleagues, supervisors, Medical Directors, and/or other programs to overcome barriers to meeting goals and objectives
Utilize case management processes in compliance with regulatory and company policies and procedures
Utilize motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations
Identify and escalate member’s needs appropriately following set guidelines and protocols
Actively reach out to members to collaborate/guide their care
Perform medical necessity reviews

Skills

Registered Nurse

Case Management

Telephonic Case Management

Clinical Guidelines

Care Planning

Utilization Management

Disease Management

URAC Accreditation

Benefit Assessment

Risk Assessment

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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