Case Manager, Registered Nurse – LTSS
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Job Description
Remote RN case manager assessing and coordinating LTSS services for CVS Health’s dual-eligible Michigan members. Conducting in-home visits and developing person-centered care plans.
Responsibilities:
- Conduct comprehensive in-home LTSS assessments to determine eligibility for waiver and community-based services
- Complete and submit required waiver documentation according to state Medicaid and health plan guidelines
- Develop and implement individualized, person-centered plans of care addressing medical, behavioral, functional, and social determinant needs
- Apply clinical judgment to identify risk factors, prevent avoidable hospitalizations, and reduce barriers to care
- Coordinate services across interdisciplinary teams, providers, home health agencies, behavioral health, and community organizations
- Review claims data, clinical records, and assessment tools to evaluate member needs and benefit utilization
- Monitor member progress and reassess needs based on changes in condition or level of care
- Present cases at interdisciplinary team meetings and collaborate with supervisors and stakeholders to ensure goal attainment
- Ensure compliance with Medicaid waiver requirements, CMS regulations, state LTSS guidelines, and company policies
- Document case management activities according to regulatory and accreditation standards
- Educate members and caregivers about benefits, services, and community resources
- Travel 25–50% within assigned counties for in-home field visits
- Work remotely with a dedicated workspace free of interruptions during standard business hours
Requirements:
- Active, unrestricted Registered Nurse (RN) license in the state of Michigan
- Associate or Bachelor of Science in Nursing (BSN preferred)
- Minimum of 2 years of clinical nursing experience
- Minimum of 1 year of experience in case management, care coordination, home health, hospice, or long-term care
- Experience working with Medicare, Medicaid, or dual-eligible populations
- Knowledge of Long-Term Services and Supports (LTSS), home and community-based services (HCBS), and waiver programs
- Experience conducting in-home assessments and developing person-centered service plans
- Strong understanding of social determinants of health and community resource navigation
- Ability to travel 25–50% within assigned counties, including completion of in-home field visits; reliable transportation is required
- Proficient in electronic medical records and care management platforms
- Experience in managed care or health plan environment
- Knowledge of Michigan Medicaid waiver programs and state LTSS regulations
- Experience presenting cases in interdisciplinary team (ICT) settings
- Strong clinical assessment and critical thinking skills
- Excellent communication and member engagement skills
- Ability to manage a high-risk, complex caseload
- Regulatory and compliance knowledge
- Independent decision-making in a remote environment
- Ability to work independently
- Effective computer skills including navigating multiple systems and keyboarding
- Proficiency with MS Word, Excel, Outlook, and PowerPoint
- Bilingual skills preferred
- Certified Case Manager (CCM) or willingness to obtain within 2 years
Benefits:
- No evenings, weekends, or major holidays
- 4 day/10-hour schedule available after training
- Medical, dental, and vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- CVS Health bonus, commission or short-term incentive program in addition to base pay
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