Case Manager Registered Nurse - Commercial Plans

CVS Health

23d

About The Position

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 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.

Requirements

• 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.

Nice To Haves

• Compact RN licensure
• Case management experience
• Case Manager Certification (e.g., CCM)
• Proficiency with Windows and Microsoft Office
• Strong computer and documentation skills

Responsibilities

• 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.

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 different needs and preferences of our 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees