Case Manager Registered Nurse; LTSS - Field MI; Southwest Michigan

Position Summary / Mission

The LTSS RN Case Manager is responsible for comprehensive assessment, care planning, coordination, implementation, and monitoring of Long‑Term Services and Supports for dual‑eligible Medicare and Medicaid members. The role ensures members receive appropriate waiver and community‑based services to promote safety, independence, and improved health outcomes while maintaining regulatory compliance. Responsibilities include on‑site in‑home visits to complete functional assessments, evaluate eligibility for waiver services, and develop person‑centered service plans.

• Conduct comprehensive in‑home LTSS assessments to determine eligibility for waiver and community‑based services.
• Complete and submit required waiver documentation in accordance with state Medicaid and health plan guidelines.
• Develop and implement individualized, person‑centered plans of care addressing medical, behavioral, functional, and social determinant needs.
• Apply clinical judgment to identify risk factors, prevent avoidable hospitalizations, and reduce barriers to care.
• Coordinate services across interdisciplinary teams including providers, home health agencies, behavioral health, and community organizations.
• Review claims data, clinical records, and assessment tools to evaluate member needs and benefit utilization.
• Monitor member progress and reassess needs based on changes in condition or level of care.
• Present cases at interdisciplinary team (ICT) meetings and collaborate with supervisors and stakeholders to ensure goal attainment.
• Ensure compliance with Medicaid waiver requirements, CMS regulations, state LTSS guidelines, and company policies.
• Document all case management activities in accordance with regulatory and accreditation standards.
• Educate members and caregivers regarding benefits, services, and available community resources.

This is a remote role with 25‑50% travel required. Candidates must have a dedicated workspace free of interruptions and be able to arrange separate care for dependents during work hours.

• Active, unrestricted Registered Nurse (RN) license in the state of Michigan.
• Associate or Bachelor of Science in Nursing (BSN preferred).
• Minimum of 2 years of clinical nursing experience.
• Minimum of 1 year of experience in case management, care coordination, home health, hospice, or long‑term care.
• Experience working with Medicare, Medicaid, or dual‑eligible populations.
• Knowledge of LTSS, home and community‑based services (HCBS), and waiver programs.
• Experience conducting in‑home assessments and developing person‑centered service plans.
• Strong understanding of social determinants of health and community resource navigation.
• Ability to travel 25–50% within assigned counties; reliable transportation required.
• Proficient in electronic medical records and care management platforms.

• Certified Case Manager (CCM) or willingness to obtain within 2 years.
• Experience in a managed care or health plan environment.
• Knowledge of Michigan Medicaid waiver programs and state LTSS regulations.
• Experience presenting cases in interdisciplinary team (ICT) settings.
• Bilingual skills preferred.

• Strong clinical assessment and critical thinking skills.
• Excellent communication and member engagement skills.
• Ability to manage a high‑risk, complex caseload.
• Regulatory and compliance knowledge.
• Independent decision‑making in a remote environment.
• Effective computer skills including navigating multiple systems and keyboarding.
• Proficiency with standard corporate software applications (MS Word, Excel, Outlook, PowerPoint).

Full‑time employees are eligible for a comprehensive benefits package that includes medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and additional resources as outlined during the application process.

CVS Health and Aetna are equal‑opportunity and affirmative action employers. We do not discriminate in recruiting, hiring, or promotion based on race, ethnicity, gender, gender identity, age, disability, or protected veteran status. We proudly support and encourage individuals with military experience and military spouses to apply.