Case Manager, Registered Nurse

CVS Health•Work At Home-Texas, NV

3d•$54,095 - $155,538•Remote

About The Position

This is a remote work-from-home role anywhere in the United States, with virtual training. The Registered Nurse Case Manager works telephonically with patients and their care teams for fully and/or self-insured clients of American Health Holding, Inc., a medical management company within Aetna/CVS Health. The role supports cost-effective, quality care and member needs through case management and medical necessity reviews.

Requirements

At least 5 years of experience as a Registered Nurse, including at least 1 year in a hospital setting.
Active RN licensure appropriate to the states supported: nurses residing in a compact state must have an active multistate license through the Nurse Licensure Compact; nurses residing in non-compact states must hold an individual RN license for each state they support.
At least 1 year of experience documenting electronically using a keyboard.
At least 1 year of current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse, or Maternity/Obstetrics.
Nursing diploma or Associate Degree in Nursing.

Nice To Haves

At least 1 year of case management, discharge planning, nurse navigator, or nurse care coordinator experience, including transferring patients to lower levels of care.
At least 1 year of Utilization Review experience.
CCM and/or other URAC-recognized accreditation.
At least 1 year of experience with MCG, NCCN, and/or Lexicomp.
Bilingual in Spanish.
Bachelor’s degree.

Responsibilities

Work intensively as a telephonic case manager with patients and their care teams.
Apply and interpret applicable criteria, clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards when assessing benefits and member needs.
Use clinical judgment to develop strategies that reduce risk factors and barriers and address complex health and social indicators affecting care planning and resolution of member issues.
Assess information from various sources to address all conditions, including comorbidities and multiple diagnoses that affect functionality.
Consult with supervisors and others to overcome barriers to goals and objectives, and present cases at case conferences for multidisciplinary review.
Consult with clinical colleagues, supervisors, Medical Directors, and other programs to overcome barriers to goals and objectives using a holistic approach.
Use case management processes in compliance with regulatory requirements and company policies and procedures.
Use motivational interviewing to engage members and understand their health status and needs.
Identify and escalate member needs according to established guidelines and protocols.
Proactively reach out to members to collaborate on and guide their care.
Perform medical necessity reviews.