Case Manager Registered Nurse - Commercial Plans

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.

Looking specifically for residents in PST due to member demographics and working hours.

Position Summary The RN Case Manager is responsible for conducting telephonic and/or in‑person assessments, developing care plans, and coordinating comprehensive case management services to support members' medical needs and promote overall wellness.

Key Responsibilities

RN Case Manager:

Develops proactive, individualized care strategies to improve both short‑ and long‑term health outcomes and enhance overall member well‑being through integrated care.

Uses clinical tools, data, and member benefit information to assess needs, determine eligibility, and ensure smooth coordination with Aetna programs and services.

Applies clinical judgment to implement strategies aimed at reducing risk factors, removing barriers, and addressing complex medical, behavioral, and social determinants that impact care plans.

Conducts holistic assessments using diverse information sources to evaluate all conditions, including co‑morbidities and multiple diagnoses that affect daily functioning.

Reviews historical claims to identify potential impacts on current case management needs and benefit eligibility.

Evaluates members' functional capacity, including work capabilities and any related restrictions or limitations.

Uses a whole‑person approach to determine when referrals to specialized clinical resources are needed to further evaluate functionality.

Collaborates with supervisors and interdisciplinary teams to address barriers, support case objectives, and participate in case conferences for comprehensive claim management.

Follows established case management protocols in alignment with regulatory requirements and company policies.

Utilizes strong interviewing and conversational skills to engage members, accurately identify health status, and understand immediate and long‑term care needs.

Required Qualifications Active, unrestricted Registered Nurse (RN) license in state of residence; multi‑state/compact licensure preferred. Must be able to obtain licensure in all non‑compact states.

Minimum of 3 years of clinical experience.

Preferred Qualifications Compact RN licensure

Case management experience

Case Manager Certification (e.g., CCM)
Proficiency with Windows and Microsoft Office Strong computer and documentation skills

Education

Position Summary The RN Case Manager is responsible for conducting telephonic and/or in‑person assessments, developing care plans, and coordinating comprehensive case management services to support members' medical needs and promote overall wellness.

Key Responsibilities

RN Case Manager:

Develops proactive, individualized care strategies to improve both short‑ and long‑term health outcomes and enhance overall member well‑being through integrated care.

Uses clinical tools, data, and member benefit information to assess needs, determine eligibility, and ensure smooth coordination with Aetna programs and services.

Applies clinical judgment to implement strategies aimed at reducing risk factors, removing barriers, and addressing complex medical, behavioral, and social determinants that impact care plans.

Conducts holistic assessments using diverse information sources to evaluate all conditions, including co‑morbidities and multiple diagnoses that affect daily functioning.

Reviews historical claims to identify potential impacts on current case management needs and benefit eligibility.

Evaluates members' functional capacity, including work capabilities and any related restrictions or limitations.

Uses a whole‑person approach to determine when referrals to specialized clinical resources are needed to further evaluate functionality.

Collaborates with supervisors and interdisciplinary teams to address…