Case Manager, Registered Nurse - Fully Remote

Case Manager, Registered Nurse - Fully Remote

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 is a remote work from home role anywhere in the US with virtual training. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost‑effective quality care for members.

• This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self‑insured clients.
• Application and/or interpretation of applicable criteria and 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.
• 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 utilize information from various sources to address all conditions including co‑morbid and multiple diagnoses that impact 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.
• Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
• 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 conversations.
• Identifies and escalates member’s needs appropriately following set guidelines and protocols.
• Need to actively reach out to members to collaborate/guide their care.
• Perform medical necessity reviews.

• 5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting.
• A Registered Nurse that holds an active, unrestricted license in their state of residence, and willingness to receive a multi‑state/compact privileges and can 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 experience.

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

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

Anticipated Weekly

Hours:

40

Time Type:
Full time

Pay Range: $54,095.00 - $

The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

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.

• 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.

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