Registered Nurse - Case Manager (Remote)

Position Overview

CVS Health is seeking dedicated colleagues passionate about transforming healthcare. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels, and over 300,000 purpose-driven colleagues. We are building a world of health around every consumer, caring for people where, when, and how they choose, in a uniquely connected, convenient, and compassionate way.

This is a remote, work-from-home role anywhere in the US with virtual training. The shift schedule is 8:30 am–5:00 pm within your time zone of residence.

American Health Holding, Inc. (AHH), a division within Aetna/CVS Health, is a medical management company founded in 1993. AHH is URAC accredited in Case Management, Disease Management, and Utilization Management, delivering flexible medical management services that support cost-effective quality care for members.

Key Responsibilities

• Serve as a telephonic case manager for patients and their care teams for fully and/or self-insured clients.
• Apply applicable criteria and clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards.
• Assess benefits and/or member needs to ensure appropriate administration of benefits.
• Utilize clinical judgment to incorporate strategies aimed at reducing risk factors and barriers, and addressing complex health and social indicators impacting care planning and issue resolution.
• Conduct assessments using information from various sources to address all conditions, including co-morbid and multiple diagnoses affecting functionality.
• Consult with supervisors and colleagues to overcome barriers in meeting goals and objectives.
• Present cases at case conferences for multidisciplinary focus to benefit overall claim management.
• Employ a holistic approach, consulting with clinical colleagues, supervisors, Medical Directors, and/or other programs to overcome barriers.
• Utilize case management processes in compliance with regulatory and company policies and procedures.
• Employ motivational interviewing skills to ensure maximum member engagement and assess health status and needs.
• Identify and escalate member needs appropriately following established guidelines and protocols.
• Actively reach out to members to collaborate and guide their care.
• Perform medical necessity reviews.

Required Qualifications

• 5+ years of experience as a Registered Nurse (RN).
• At least 1 year of experience in a hospital setting.
• Active, unrestricted RN license in your state of residence.
• Willingness to obtain multi-state/compact privileges and be licensed in all non-compact states.
• 1+ years of experience documenting electronically using a keyboard.
• 1+ years of current or previous experience in Oncology or Specialty Pharmacy.

Preferred Qualifications

• 1+ years of Case Management experience, discharge planning, nurse navigator, or nurse care coordinator experience.
• Experience with transferring patients to lower levels of care.
• 1+ years of experience in Utilization Review.
• CCM and/or other URAC recognized accreditation preferred.
• 1+ years of experience with MCG, NCCN, and/or Lexicomp.
• Bilingual in Spanish preferred.

Education

• Diploma or Associate Degree in Nursing required.
• BSN preferred.

Employment Type

• Full time

Anticipated Weekly Hours

• 40

Pay Range

• The typical pay range for this role is: $54,095.00 - $155,538.00. This range represents the base salary offer, which will depend on factors including experience, education, and geography.