Case Manager, Registered Nurse - Work from Home

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.

This is a remote work from home role anywhere in the US with virtual training. Shift schedule is 8:30am - 5pm within time zone of residence. 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.

This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives Utilizes case management processes in compliance with regulatory and company policies and procedures Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations Identifies and escalates member’s needs appropriately following set guidelines and protocols Need to actively reach out to members to collaborate/guide their care Perform medical necessity reviews