Case Manager, Registered Nurse - Fully Remote
Join to apply for the Case Manager, Registered Nurse - Fully Remote role at CVS Health .
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.
Position Summary
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.
Key Responsibilities
Work as a telephonic case manager with patients and their care team for fully and/or self‑insured clients.
Apply and interpret 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.
Use clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.
Assess conditions utilizing information from various sources to address all diagnoses that impact functionality.
Consult with supervisor and others in overcoming barriers in meeting goals and objectives, presenting cases at case conferences for multidisciplinary focus to benefit overall claim management.
Collaborate with clinical colleagues, supervisors, Medical Directors and other programs to overcome barriers and meet goals.
Follow case management processes in compliance with regulatory and company policies and procedures.
Use motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations.
Identify and expedite member’s needs appropriately following set guidelines and protocols.
Actively reach out to members to collaborate and guide their care.
Perform medical necessity reviews.
Required Qualifications
5+ years experience as a Registered Nurse with at least 1 year in a hospital setting.
Active, unrestricted RN license in the state of residence; ability to obtain multi‑state/compact privileges and license in all non‑compact states.
1+ year experience documenting electronically using a keyboard.
1+ year experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics.
Preferred Qualifications
1+ year case management or discharge planning, nurse navigator, or nurse care coordinator experience including transferring patients to lower levels of care.
1+ year utilization review experience.
CCM and/or other URAC‑recognized accreditation preferred.
1+ year experience with MCG, NCCN and/or Lexicomp.
Bilingual in Spanish preferred.
Education
Diploma or Associate’s Degree in Nursing required.
BSN preferred.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
$54,095.00 – $155,538.00 (base hourly rate or base annual full‑time salary for all positions in the job grade). Actual base salary offer will depend on experience, education, geography and other factors.
Great Benefits
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 needs and preferences of 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.
For more information about benefits, visit https://jobs.cvshealth.com/us/en/benefits
This job does not have an application deadline; CVS Health accepts applications on an ongoing basis.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.