Description
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 themselves accountable and prioritize safety and quality in everything we do.
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 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.
- 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 with at least 1 year of experience 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).
- 1+ years' experience documenting electronically using a keyboard.
- 1+ years' current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics experience.
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.
- Bachelor's degree preferred.
Education
- Nursing diploma or Associate's 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.