Organization Overview
CVS Health® is committed to building a healthier world around every individual by creating more connected, convenient, and compassionate health experiences. Through innovation, accountability, and a strong focus on safety and quality, the organization supports individuals, families, and communities across the United States. American Health Holding, Inc. (AHH), a division of Aetna and CVS Health, has been delivering accredited medical management services since 1993 and is recognized by URAC for excellence in case management, disease management, and utilization management.
Role Summary
The Case Manager, Registered Nurse role is a fully remote position available across 49 locations in the United States. This position focuses on telephonic case management and involves close collaboration with patients and multidisciplinary care teams. The role supports fully insured and self-insured clients while ensuring cost-effective, high-quality care delivery. Virtual training is provided, enabling nurses to work from home while maintaining clinical excellence.
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Primary Focus Areas
Integrated Case Management and Patient Engagement
The case manager works intensively with members and their care teams, using structured care management plans, clinical guidelines, and regulatory standards to ensure appropriate benefit administration and optimal care outcomes. Moreover, the role emphasizes proactive outreach to members to guide and coordinate their care journeys.
Clinical Assessment and Care Planning
Comprehensive assessments are conducted using information from multiple sources to address comorbidities, various diagnoses, and functional limitations. Clinical judgment is applied to identify risk factors, social determinants, and barriers that may impact care planning and resolution of complex cases.
Collaboration and Multidisciplinary Support
Using a holistic approach, the nurse collaborates with clinical colleagues, supervisors, medical directors, and specialized programs. In addition, cases are presented during case conferences to support multidisciplinary decision-making and improve overall claim and care management.
Compliance, Quality, and Utilization Review
The role requires strict adherence to regulatory requirements, company policies, and case management processes. Responsibilities also include conducting medical necessity reviews and appropriately escalating member needs in accordance with established protocols.
Motivational Interviewing and Member Advocacy
Motivational interviewing techniques are used to enhance member engagement, assess health status, and identify unmet needs. Through meaningful conversations, the case manager supports members in achieving improved health outcomes.
Required Candidate Profile
Required Qualifications
Candidates must have at least 5 years of experience as a Registered Nurse, including at least 1 year in a hospital setting. An active and unrestricted Registered Nurse license in the state of residence is required, along with a willingness to obtain multi-state or compact privileges and licensure in states as needed. In addition, applicants should have at least 1 year of experience with electronic documentation using a keyboard and a relevant clinical background in oncology, transplant, specialty pharmacy, pediatrics, medical-surgical care, behavioral health, substance abuse, or maternity and obstetrics.
Preferred Qualifications
Preferred candidates will bring prior experience in case management, discharge planning, nurse navigation, or care coordination, particularly with transitioning patients to lower levels of care. Experience in utilization review, familiarity with tools such as MCG, NCCN, or Lexicomp, and recognized accreditations such as CCM or other URAC-approved credentials are advantageous. Bilingual proficiency in Spanish is also preferred.
Education Requirements
A diploma or associate degree in nursing is required for this role. However, a Bachelor of Science in Nursing is strongly preferred.
Work Schedule and Employment Type
This position is full-time, with an anticipated 40-hour workweek.
Compensation and Benefits
The typical pay range for this role is competitive, ranging from USD 54,095 to USD 155,538 annually. Final compensation is determined based on experience, education, geographic location, and other relevant factors.
CVS Health offers a comprehensive benefits package designed to support physical, emotional, and financial well-being. Benefits include affordable medical plans, a 401(k) with company matching, employee stock purchase plans, wellness programs, confidential counseling, financial coaching, paid time off, flexible scheduling, family leave, tuition assistance, and additional support programs, subject to eligibility.
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Application Process
CVS Health accepts applications for this role on an ongoing basis, with no fixed deadline. Interested candidates are encouraged to apply through the official CVS Health careers portal, where detailed application instructions and current opportunities are available.
Additional Information
Qualified applicants with arrest or conviction records will be considered in accordance with applicable federal, state, and local laws. CVS Health remains committed to diversity, equity, and inclusion, ensuring that every colleague feels valued and supported.