Case Manager, Registered Nurse - Compact RN ; Remote

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.

This Case Manager
- Registered Nurse (RN) position is with Aetna’s National Medical Excellence (NME) team and is a fully remote position. Candidates from any state are welcome to apply, however, preference is for candidates in compact Registered Nurse (RN) states.

This role is a blended role doing both Case Management and Utilization Management. The RN Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness.

• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration.
• Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• 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 consider information from various sources to address all conditions including co‑morbid and multiple diagnoses that impact functionality.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Assessments include the member’s level of work capacity and related restrictions/limitations.
• Using a holistic approach assess the need for a referral to clinical resources for assistance in determining 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.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

• Candidate must have an active, current and unrestricted compact Registered Nurse (RN) licensure in the state of residence
• 5 years clinical practice experience as an Registered Nurse (RN)
• 2+ years’ experience in critical care
• 6+ months case management or utilization management experience
• Must be able to work Monday
  - Friday 8 AM to 5 PM in the time zone of residence (There are currently no nights, weekends, and holidays; however, is subject to change based on business needs)
• Must be able to obtain multi state Registered Nurse (RN) licensures

• Case Management Certification
• Transplant experience

• Associate's Degree in Nursing (REQUIRED)
• Bachelor's Degree in Nursing (PREFERRED)

• Must have an active, current and unrestricted compact Registered Nurse (RN) licensure in the state of residence

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 Mbps download and 3 Mbps upload. WiFi and satellite internet are not permitted.
• A quiet,…