Case Manager, Registered Nurse - Fully Remote

Position Summary

This is a remote work-from-home role anywhere in the U.S. with virtual training. American Health Holding, Inc. (AHH) is a medical management division within Aetna/CVS Health. AHH is URAC accredited in Case Management, Disease Management, and Utilization Management, delivering flexible services to support cost-effective quality care for members.

Key Responsibilities

• This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients.
• Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, policies, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits.
• Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues.
• Assessments utilize information from various sources to address all conditions including co-morbidity and multiple diagnoses that impact functionality.
• 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.
• Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations.
• Identifies and escalates member's needs appropriately following set guidelines and protocols.
• Need to actively reach out to members to collaborate/guide their care.
• Perform medical necessity reviews.

Required Qualifications

• 5+ years' experience as a Registered Nurse with at least 1 year of experience in a hospital setting.
• The AHH RN Case manager position requires the nurse to support members across multiple states. An 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.
• 1+ year of experience documenting electronically using a keyboard.
• 1+ year of current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics.

Preferred Qualifications

• 1+ year of 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.
• 1+ year of experience in Utilization Review.
• CCM and/or other URAC recognized accreditation preferred.
• 1+ year of experience with MCG, NCCN and/or Lexicomp.
• Bilingual in Spanish preferred.

Education

• Diploma or Associates Degree in Nursing required.
• BSN preferred.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

$54,095.00 – $155,538.00. This 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.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

EEO Statement

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.