Registered Nurse Case Manager

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.

This is a remote work from home role anywhere in the US with virtual training.

Position Summary 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 intensely 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.
• 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.
• Conduct assessments utilizing information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Consult with supervisor and others in overcoming barriers in meeting goals and objectives, present cases at case conferences for multidisciplinary focus to benefit overall claim management.
• Use a holistic approach to consult with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
• Utilize 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.
• Identify and escalate member's needs appropriately following set guidelines and protocols.
• Actively reach out to members to collaborate/guide their care.
• Perform medical necessity reviews.

Required Qualifications

• 5+ years' experience as a Registered Nurse, including at least 1 year in a hospital setting.
• The AHH RN Case manager position requires the nurse to support members across multiple states. A RN who resides in a compact state is required to have an active multistate license through the Nurse Licensure Compact (NLC), allowing practice across participating states with one license.
• 1+ years' experience documenting electronically using a keyboard.
• 1+ years' current or previous experience in Oncology.

Preferred Qualifications

• 1+ years' Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience.
• 1+ years' experience in Utilization Review.
• CCM and/or other URAC recognized accreditation preferred.
• 1+ years' experience with MCG, NCCN and/or Lexicomp.
• Bilingual in Spanish preferred.
• BSN Preferred.

Education

• Diploma or Associates Degree in Nursing required.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range $54,095.00 - $155,538.00

Benefits We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.