nurse case manager

ECHO

<div><p><b>Primary Purpose:</b></p><p>
To provide support and facilitate care for members who require case management. To work collaboratively with the Health Plan and Hospital Case Management Departments to facilitate services. To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the provision of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual&rsquo;s health needs through communication and available resources to promote quality and cost-effective outcomes. If applicable, the CM will coordinate care for Cal Medi-Connect program members to ensure that all aspects of the CMC program description are implemented and followed. All services under Medicare and Medi-Cal will be coordinated and monitored, including CCS, IHSS, CBAS, and BH. The case manager is a licensed nurse (RN or LVN). A care manager can be a licensed social worker (MSW) or a licensed nurse (RN or LVN).</p><p>
All candidates for any position within case management will have the appropriate education and experience to meet requirements and the service needs of the population.</p><p><b>
Principal Duties and Responsibilities (* = essential functions):</b></p><ul><li>
To utilize the Case Management functions: assessor, planner, facilitator, advocate. *</li><li>
To facilitate services at the appropriate Health Plan center of excellence. *</li><li>
To utilize the most cost-effective case rates and contracts. *</li><li>
To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services across the continuum of care. *</li><li>
To perform catastrophic case management as appropriate to the patient&rsquo;s medical condition and healthcare needs, utilizing the standards of practice for Case Management.</li><li>
To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information. *</li><li>
Preparing for and participating in health plan audits onsite as required.</li><li>
To actively participate in Utilization Management Committees regarding Case Presentations and problem-solving.</li><li>
To participate in the development of Case Management Policies and Procedures.</li><li>
To actively participate in the discharge planning process.</li><li>
To monitor and participate in the SNP/Duals program</li><li>
To monitor and participate in the CMC program</li><li>
To ensure all members are living in the least restrictive environment</li><li>
To follow the UM/QI/CM/SNP/CMC program descriptions</li><li><b>
Assigned to On-Call after-hours Customer Service Care.</b></li><li>
To perform other duties as assigned.</li></ul><p><b>
Job Specifications (KSAs):</b></p><ul><li>
Requires extensive and specialized knowledge of utilization and case management processes, generally acquired through 2-3 years or more of experience as a case manager in a Managed Care Environment, or through successful completion of a nursing program.</li><li>
Requires prior Case Management experience, preferably with catastrophic cases.</li><li>
Requires an active RN or LVN license in the state of employment.</li><li>
Requires clinical expertise, generally acquired through 3 to 5 years of acute nursing practice.</li><li>
Requires excellent written and verbal communication skills.</li><li>
Requires computer experience, particularly with Microsoft Word and Excel, familiarity with Cozeva (a plus), and the ability to learn new software applications quickly.</li><li>
Requires problem-solving and critical thinking skills.</li><li>
Requires professional demeanor and the ability to contribute to a positive work environment.</li><li>
Requires knowledge of regulatory standards such as Medicare, TitleXXII, and Medi-Cal*</li><li>
Requires extensive knowledge of health plan guidelines.</li></ul><p><b>
Position Performance Criteria:</b></p><ul><li>
Demonstrates proficiency in UM and Case Management, including but not limited to:</li></ul><ul><li>
Catastrophic Case Management</li><li>
Transplant Management</li><li>
Referral review</li><li>
Out-of-network management</li><li>
Denial letter process</li><li>
Concurrent/inpatient review and bed-day management.</li><li>
Demonstrates the effective practice of Case Management Standards of Care, including:</li></ul><ul><li>
Assessment</li><li>
Case Identification and Selection</li><li>
Planning</li><li>
Monitoring</li><li>
Evaluating</li><li>
Outcomes</li><li>
Sets appropriate priorities to meet departmental goals and objectives, including but not limited to:</li></ul><ul><li>
Demonstrates ability to efficiently manage case load.</li><li>
Demonstrates ability to set appropriate priorities</li><li>
Consistently makes prudent and sound decisions</li><li>
Manages multiple tasks while meeting required timeframes</li><li>
Adheres to departmental policies and procedures</li></ul><ul><li>
Demonstrate knowledge of Health Plan guidelines.</li><li>
Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.</li></ul><ul><li>
Ensures consistency in the application of the utilization process.</li><li>
Maintains knowledge of new legislation and disseminates information to providers and co-workers.</li></ul><ul><li>
Demonstrates ability to give concise, articulate, and accurate case presentations to Medical Director, UMC, etc., including problem-solving.</li><li>
Demonstrates cost savings.</li><li>
Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:</li></ul><ul><li>
Professional appearance and demeanor</li><li>
Meets departmental attendance needs on-site</li><li>
Participates verbally in group activities, i.e., staff meetings, etc.</li><li>
Demonstrates respect for co-workers and customers.</li><li>
Works collaboratively with other departments to identify and resolve issues.</li></ul><p></p><p><br>
Hourly Range is: $33.50 to $45.00 per hour</p></div>

Inpatient Nurse Case Manager

Alignment Healthcare

<div><p>Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.</p><p></p>
Location: Fully Remote (Must be licensed in California)<br>
Schedule: Monday&ndash;Friday, 8:00 AM &ndash; 5:00 PM PT<br>
Language: Bilingual candidates strongly preferred (Spanish and Vietnamese)<br>
<br>
Join the Team That&rsquo;s Redefining Healthcare!<br>
<br>
Are you a compassionate Registered Nurse with a passion for improving the lives of seniors and complex care patients? Join Alignment Health as a Telephonic RN Case Manager for our Special Needs Plan (SNP) members &mdash; all from the comfort of your home!<br>
<br>
This is a fully remote, phone-based position where you'll play a vital role in helping members navigate their care journeys, close gaps in care, and overcome barriers to better health. (HIPAA compliant work space)<p></p><div><div><b>
What You'll Do</b></div><div>
As an <b>RN Case Manager (SNP)</b>, you will:</div><ul><li><div>
Provide telephonic case management to <b>medically complex and chronically ill members</b></div></li><li><div>
Conduct <b>comprehensive health assessments</b> and create individualized care plans</div></li><li><div>
Coordinate care with internal and external partners, including physicians and specialists</div></li><li><div>
Educate members and caregivers on disease management and preventive care</div></li><li><div>
Monitor member progress and advocate for timely, appropriate interventions</div></li><li><div>
Identify and help resolve service or access issues impacting care quality</div></li></ul><div></div><div><b>
Requirements</b></div><div><b>
Must-Haves:</b></div><ul><li><div><b>
Active, unrestricted RN license in California</b> (Non-Compact)</div></li><li><div><b>
Minimum 2 years of clinical nursing experience</b></div></li><li><div><b>
At least 1 year of case management</b> experience</div></li><li>
Proficiency with Microsoft Office (Word, Excel, Outlook)</li></ul><div></div><div><b>
Nice-to-Haves:</b></div><ul><li><div>
Bilingual (Spanish, Korean, Mandarin, etc.)</div></li><li><div>
Previous <b>health plan</b> or <b>IPA</b> experience</div></li><li><div>
Bachelor's Degree in Nursing (BSN)</div></li></ul><div></div><div><b>
Licensure Requirement Upon Hire:</b></div><ul><li><b>
Active, unrestricted RN license in California</b> (Non-Compact)</li><li><div>
Must be willing to obtain RN licensure in <b>Nevada</b>, <b>Arizona</b>, <b>North Carolina</b>, and <b>Texas</b> (company reimburses costs)</div></li></ul><div></div><div><b>
Work Environment</b></div><ul><li><div><b>
Fully remote</b> &mdash; work from anywhere in the U.S., but must work <b>Pacific Time hours</b></div></li><li><div>
All communication is conducted via phone, email and Teams.</div></li><li><div>
Company-provided equipment and IT support included</div></li></ul><div></div><div><b>
Why Join Alignment Health?</b></div><div>
At Alignment, we&rsquo;re changing the way healthcare is delivered for the most vulnerable populations. We're committed to innovation, compassion, and delivering meaningful outcomes &mdash; and we want <b>you</b> to be a part of that journey.</div><div></div><div><b>
Benefits &amp; Perks</b></div><ul><li><div>
Competitive compensation</div></li><li><div>
Full suite of health benefits (medical, dental, vision)</div></li><li><div>
401(k) with employer match</div></li><li><div>
Generous PTO and paid holidays</div></li><li><div>
Career growth and continuing education support</div></li><li><div>
Rewarding referral bonuses for successful hires</div></li></ul><div></div><div><b>
Apply Today</b></div><div>
Be part of something bigger. Bring your skills and compassion to a team that values connection, service, and innovation.</div><div></div><div>
Apply now or refer a colleague who would thrive in this role:</div><div>
https://careers.alignmenthealth.com</div><div></div><div><b>
Note:</b> This position is not open to LVNs. California RN license is required.</div></div><div></div><div><div><div><div><p>
Essential Physical Functions:</p><p>
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p><ul><li>
While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.</li><li>
The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.</li></ul></div></div></div></div>
Pay Range: $77,905.00 - $116,858.00<p>
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
</p><p></p><p>Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.</p><p></p><ul><li><i>DISCLAIMER: Please</i><i> beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal </i><i>information. Please</i><i> be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at </i><i>https://reportfraud.ftc.gov/#/</i><i>. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health&rsquo;s talent acquisition team, please email </i><i>careers@ahcusa.com</i><i>.</i></li></ul></div>

Remote Bilingual Spanish Telephonic RN Nurse Case Manager (California RN Required)

Enlyte

<div>Company Overview:
<div>
At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth.</div><div></div><div><b><br>
Be part of a team that makes a real difference.</b></div>
Job Description:
<div><b>
This is a full-time, hybrid position. The candidate must be located in the </b><b>Washington, DC</b><b> </b><b>area due to regular local travel for in-person patient appointments.</b></div><div></div><div><b><br>
Perks: </b>Full and comprehensive benefits program, 24 days of paid vacation/holidays in your first year plus sick days, home office equipment including laptop and desktop monitor, mileage and travel reimbursement, Employee Assistance and Referral Program, and hands-on workers&rsquo; compensation case management training.</div><div></div><div><br>
Join our compassionate team and help make a positive difference in an injured person&rsquo;s life. As a Field Case Manager, you will work closely with treating physicians/providers, employers, customers, legal representatives, and the injured/disabled person to create and implement a treatment plan that returns the injured/disabled person back to work appropriately, ensure appropriate and cost-effective healthcare services, achievement of maximum medical recovery and return to an optimal level of work and functioning. In this role, you will:</div><ul><li>
Demonstrate knowledge, skills, and competency in the application of case management standards of practice.
</li><li>Use advanced knowledge of types of injury, medications, comorbidities, treatment options, treatment alternatives, and knowledge of job duties to advise on a treatment plan.</li><li>
Interview disabled persons to assess overall recovery, including whether injuries or conditions are occupational or non-occupational.</li><li>
Collaborate with treating physicians/providers and utilize available resources to help create and implement treatment plans tailored to an individual patient.</li><li>
Work with employers and physicians to modify job duties where practical to facilitate early return to work.</li><li>
Evaluate and modify case goals based on injured/disabled person&rsquo;s improvement and treatment effectiveness.</li><li>
Independently manage workload, including prioritizing cases and deciding how best to manage cases effectively.
</li><li>Complete other duties, such as attend injured worker&rsquo;s appointments when appropriate, prepare status updates for submittal to customers, and other duties as assigned.</li></ul>
Qualifications:
<ul><li><b>Education:</b> Associates Degree or Bachelor&rsquo;s Degree in Nursing or related field.</li><li><b>
Experience:</b> 2+ years clinical practice preferred. Workers&rsquo; compensation-related experience preferred.</li><li><b>
Skills:</b> Ability to advocate recommendations effectively with physicians/providers, employers, and customers. Ability to work independently. Knowledge of basic computer skills including Excel, Word, and Outlook Email. Proficient grammar, sentence structure, and written communication skills.</li><li><b>
Certifications, Licenses, Registrations:
</b><ul><li>Active Registered Nurse (RN) license required. Must be in good standing.</li><li>
URAC-recognized certification in case management (CCM, CDMS, CRC, CRRN or COHN, COHN-S, RN-BC, ACM, CMAC, CMC) preferred.</li></ul></li><li><b>
Travel: </b>Must have reliable transportation and be able to travel to and attend in-person appointments with injured workers in assigned geography.</li><li><b>
Internet:</b> Must have reliable internet.</li></ul>
Benefits:
<div>
We&rsquo;re committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&amp;D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living. Benefits eligibility may differ depending on full-time or part-time status. Compensation depends on the applicable US geographic market. The expected base pay for this position ranges from $79,000 - $90,000 annually. In addition to the base salary, you will be eligible to participate in our productivity-based bonus program. Your total compensation, including base pay and potential bonus, will be based on a number of factors including skills, experience, education, and performance metrics.</div><div><br>
</div><p><i>The Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.</i>
</p><p>#LI-AC1</p><div></div><div><br>
Registered Nurse (RN), Nursing, Home Care Registered Nurse, Emergency Room Registered Nurse, Clinical Nurse, Nurse Case Manager, Field Case Manager, Medical Nurse Case Manager, Workers&rsquo; Compensation Nurse Case Manager, Critical Care Registered Nurse, Advanced Practice Registered Nurse (APRN), Nurse Practitioner, Case Management, Case Manager, Home Healthcare, Clinical Case Management, Hospital Case Management, Occupational Health, Patient Care, Utilization Management, Acute Care, Orthopedics, Rehabilitation, Rehab, CCM, Certified Case Manager, CDMS, Certified Disability Management Specialist, CRC, Certified Rehab Certificate, CRRN, Certified Rehab Registered Nurse, COHN, Certified Occupational Health Nurse, CMC, Cardiac Medicine Certification, CMAC, Case Management Administrator Certification, ACM, Accredited Case Manager, MSW, Masters in Social Work, URAC, Vocational Case Manager</div></div>

Medical Field Case Manager

Interim HealthCare

<div><p><b>Description</b><br>
</p><br>
<p>As a Hospice Registered Nurse Case Manager (RN) you will be called to care when you're needed most. As part of Interim HealthCare, you'll support a full range of patient services to bring comfort and dignity to our clients.</p><p>
What we offer our Hospice Registered Nurse Case Manager (RN):</p><ul><li>
Competitive pay, benefits, and incentives</li><li>
Truly flexible scheduling - a dedication to work/life balance - Full-time (FT)</li><li>
Daily Pay option available</li><li>
One-on-One patient care</li></ul><p>
Working at Interim HealthCare means a career unlike any other. With integrity at the center of all we do, we know that when we support you and your community, you'll change lives every day.</p><p>
As a Hospice Registered Nurse Case Manager (RN), you will:</p><ul><li>
Oversee the implementation and ongoing assessment of the patient's plan of care alongside the spiritual care coordinator, social worker, hospice aide and medical director
</li><li>Ensure an accurate evaluation and work to develop and implement a comprehensive care plan that addresses patient needs
</li><li>Communicate patient conditions and collaborate with appropriate providers to deliver care when patient needs evolve</li></ul><p>
To qualify for a Hospice Registered Nurse Case Manager (RN) with us, you will need:</p><ul><li>
Education: Associate degree in Nursing (ADN) or Associate of Applied Science in Nursing (AAS) required; Bachelor of Science in Nursing (BSN) preferred
</li><li>Licensure: Current license to practice as a Registered Nurse (RN) in the state associated with this position.
</li><li>Current CPR/FA certification
</li><li>Reliable transportation to/from care sites and/or work locations
</li><li>One (1) year of professional experience practicing as a Registered Nurse (RN) in a hospice or similar setting preferred</li></ul><p>
At Interim HealthCare Hospice &amp; Palliative Care, we know that being our best is non-negotiable - that's why we treat your family like our own. We take a patient-centric approach to address each individual's mind, body, and spirit, our caregivers work tirelessly to help their patients and families find peace. From our unmatched referral response times to our focus on quality improvement, the most beautifully complicated time of your life is our life's work.</p><p>
We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.</p><p>
#Hospice1</p></div>

Hospice RN Case Manager

CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Position Summary</b></p><p></p><p><b>
This is a remote work from home role anywhere in the US with virtual training.</b></p><p></p><p>
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.</p><p></p><p><b>
Key Responsibilities</b></p><ul><li><p>
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients.</p></li><li><p>
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&rsquo;s needs to ensure appropriate administration of benefits.</p></li><li><p>
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.</p></li><li><p>
Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.</p></li><li><p>
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.</p></li><li><p>
Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.</p></li><li><p>
Utilizes case management processes in compliance with regulatory and company policies and procedures.</p></li><li><p>
Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations.</p></li><li><p>
Identifies and escalates member&rsquo;s needs appropriately following set guidelines and protocols.</p></li><li><p>
Need to actively reach out to members to collaborate/guide their care.</p></li><li><p>
Perform medical necessity reviews.</p></li></ul><p><b><br>
Required Qualifications</b></p><ul><li><p>
5+ years&rsquo; experience as a Registered Nurse, including at least 1 year in a hospital setting.</p></li><li><p>
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. Nurses residing in non‑compact states must hold an individual, state‑specific RN license for each state they support</p></li><li><p>
1+ years&rsquo; experience documenting electronically using a keyboard.</p></li><li><p>
1+ years&rsquo; current or previous experience in Oncology.</p></li></ul><p><b><br>
Preferred Qualifications</b></p><ul><li><p>
1+ years&rsquo; Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care.</p></li><li><p>
1+ years' experience in Utilization Review.</p></li><li><p>
CCM and/or other URAC recognized accreditation preferred.</p></li><li><p>
1+ years&rsquo; experience with MCG, NCCN and/or Lexicomp.</p></li><li><p>
Bilingual in Spanish preferred.</p></li><li><p>
Bachelors Degree</p></li></ul><p><b><br>
Education</b></p><ul><li><p>
Diploma or Associates Degree in Nursing required.</p></li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$54,095.00 - $155,538.00<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
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. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis.<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Case Manager, Registered Nurse (Oncology experience required)

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Position Summary</b></p><p><b>
This is a remote work from home role anywhere in the US with virtual training.</b></p><p></p><p>
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.</p><p></p><p><b>
Key Responsibilities</b></p><ul><li><p>
This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients.</p></li><li><p>
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&rsquo;s needs to ensure appropriate administration of benefits.</p></li><li><p>
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.</p></li><li><p>
Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.</p></li><li><p>
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.</p></li><li><p>
Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.</p></li><li><p>
Utilizes case management processes in compliance with regulatory and company policies and procedures.</p></li><li><p>
Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations.</p></li><li><p>
Identifies and escalates member&rsquo;s needs appropriately following set guidelines and protocols.</p></li><li><p>
Need to actively reach out to members to collaborate/guide their care.</p></li><li><p>
Perform medical necessity reviews.</p></li></ul><p><b><br>
Required Qualifications</b></p><ul><li><p>
5+ years&rsquo; experience as a Registered Nurse with at least 1 year of experience in a hospital setting.</p></li><li><p>
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. Nurses residing in non‑compact states must hold an individual, state‑specific RN license for each state they support.</p></li><li><p>
1+ years&rsquo; experience documenting electronically using a keyboard.</p></li><li><p>
1+ years&rsquo; current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/ Obstetrics experience.</p></li></ul><p><b><br>
Preferred Qualifications</b></p><ul><li><p>
1+ years&rsquo; Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care.</p></li><li><p>
1+ years' experience in Utilization Review.</p></li><li><p>
CCM and/or other URAC recognized accreditation preferred.</p></li><li><p>
1+ years&rsquo; experience with MCG, NCCN and/or Lexicomp.</p></li><li><p>
Bilingual in Spanish preferred.</p></li></ul><p><b><br>
Education</b></p><ul><li><p>
Diploma or Associates Degree in Nursing required.</p></li><li><p>
BSN preferred.</p></li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$54,095.00 - $155,538.00<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
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. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis.<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

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