Case Manager, Registered Nurse
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Job Description
Telephonic RN case manager coordinating member care and medical necessity reviews for CVS Health’s American Health Holding division. Applying clinical guidelines across complex conditions and multiple states.
Responsibilities:
- Work intensely as a telephonic case manager with patients and their care teams for fully and/or self-insured clients
- Apply and interpret applicable criteria, clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards
- Assess benefits and member needs to ensure appropriate administration of benefits
- Apply clinical judgment to reduce risk factors and barriers and address complex health and social indicators affecting care planning
- Conduct assessments using information from various sources, including co-morbid and multiple diagnoses affecting functionality
- Consult with supervisors and others to overcome barriers and meet goals and objectives
- Present cases at case conferences for multidisciplinary review and overall claim management
- Consult with clinical colleagues, supervisors, Medical Directors, and other programs using a holistic approach
- Use case management processes in compliance with regulatory and company policies and procedures
- Use motivational interviewing to maximize member engagement and determine health status and needs
- Identify and appropriately escalate member needs following guidelines and protocols
- Actively reach out to members to collaborate on and guide their care
- Perform medical necessity reviews
Requirements:
- 5+ years’ experience as a Registered Nurse, including at least 1 year of experience in a hospital setting
- Active multistate RN license through the Nurse Licensure Compact (NLC) for nurses residing in compact states, or individual state-specific RN licenses for each supported state for nurses in non-compact states
- 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
- Nursing diploma or Associates Degree in Nursing required
- 1+ years’ Case Management, discharge planning, nurse navigator, or nurse care coordinator experience preferred
- 1+ years’ experience transferring patients to lower levels of care preferred
- 1+ years’ experience in Utilization Review preferred
- CCM and/or other URAC recognized accreditation preferred
- 1+ years’ experience with MCG, NCCN, and/or Lexicomp preferred
- Bilingual in Spanish preferred
- Bachelor’s degree preferred
Benefits:
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- Virtual training
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