Case Manager RN- Pennsylvania at CVS Health

About the position The Case Manager RN role at CVS Health is a fully remote position, requiring candidates to reside and hold an active RN license in the state of Pennsylvania. This role is pivotal in delivering human-centric health care, aligning with CVS Health's commitment to enhancing the health care experience for members. The Case Manager RN will engage in telephonic and face-to-face assessments, planning, implementing, and coordinating case management activities to evaluate and address the medical needs of members. The position emphasizes a holistic approach to care, integrating clinical judgment and strategies to improve health outcomes and overall wellness for members. In this role, the RN will develop proactive action plans to tackle issues that may affect both short and long-term health outcomes. Utilizing clinical tools and data review, the RN will assess members' needs, eligibility for benefits, and facilitate smooth transitions to Aetna programs. The RN will also conduct comprehensive evaluations that consider co-morbid conditions and multiple diagnoses impacting functionality. This includes reviewing prior claims to understand their influence on current case management and eligibility. The RN will engage with members through effective interviewing techniques to ensure maximum engagement and understanding of their health status and needs. The Case Manager RN will collaborate with supervisors and multidisciplinary teams to overcome barriers to achieving health goals, presenting cases at conferences to ensure comprehensive claim management. Compliance with regulatory and company policies is essential, as is the ability to work flexible hours, including occasional evenings, weekends, and holidays as needed by the team. This position not only requires clinical expertise but also a commitment to CVS Health's mission of making health care more personal, convenient, and affordable. The RN will play a crucial role in transforming the culture of care at CVS Health, ensuring that every interaction is guided by the organization's core values and purpose. Responsibilities • Telephonically and/or face-to-face assess members' medical needs. , • Plan, implement, and coordinate all case management activities with members. , • Develop proactive action plans to enhance short and long-term health outcomes. , • Conduct evaluations of members' needs and benefit plan eligibility. , • Facilitate smooth transitions to Aetna programs and plans. , • Apply clinical judgment to reduce risk factors and address complex health indicators. , • Review prior claims to assess their impact on current case management. , • Assess members' work capacity and related restrictions/limitations. , • Utilize a holistic approach to determine the need for referrals to clinical resources. , • Consult with supervisors and multidisciplinary teams to overcome barriers to care. , • Present cases at case conferences for collaborative focus on claim management. , • Utilize case management processes in compliance with regulatory and company policies. , • Engage members through effective interviewing skills to discern health status and needs. Requirements • Active, current, and unrestricted RN licensure in the state of Pennsylvania. , • Must reside in Pennsylvania. , • 2+ years of clinical experience as an RN in various settings (e.g., Emergency Department, Home Health, Hospice, etc.). , • Willingness to obtain multiple state RN licensure after hire (expenses covered by the company). , • Ability to work Monday through Friday from 9:00am - 5:30pm EST. , • Willingness to work occasional evening, weekend, and holiday shifts. Nice-to-haves • Certified Case Manager (CCM) certification. , • Experience in case management within an integrated model. , • Discharge planning experience. , • Managed care experience. Benefits • Full range of medical, dental, and vision benefits. , • 401(k) retirement savings plan. , • Employee Stock Purchase Plan for eligible employees. , • Fully-paid term life insurance plan. , • Short-term and long-term disability benefits. , • Well-being programs and education assistance. , • Free development courses. , • CVS store discount and discount programs with partners. , • Paid Time Off (PTO) and paid holidays throughout the year. Apply Job!