Case Manager Registered Nurse - Medicare; Remote

Description

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

• Location: Work From Home - Flexible,
  
  Travel Required:
  
  25 - 50% (Wayne and Macomb Counties)
• Schedule: Standard business hours Monday-Friday 8:00am-5:00pm EST
• No evenings, weekends, or major holidays
• 4‑day/10‑hour schedule available after training

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

Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best‑in‑class operating and clinical models. You can have life‑changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs.

• 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.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

• 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 Long‑Term Services and Supports (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 is required.
• Proficient in electronic medical records…