Shift schedule is 8:30am - 5pm within time zone of residence.

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.

- 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, polices, procedures and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits
- 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
- Assessments utilize information from various sources to address all conditions including co-morbid 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

- A Registered Nurse that holds an active, unrestricted license in their state of residence, and willingness to receive a multi-state/compact privileges and can be licensed in all non-compact states

- 1+ years' experience documenting electronically using a keyboard

- 1+ years' current or previous experience in Oncology, Behavioral Health/Substance Abuse, Maternity, Maternal Newborn, Transplant, Pediatric, Medical/Surgical, or Specialty Pharmacy

Preferred Qualifications

- 1+ years' 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+ years' experience in Utilization Review

- CCM and/or other URAC recognized accreditation preferred

- 1+ years' experience with MCG, NCCN and/or Lexicomp

- Bilingual in Spanish preferred

Education

- Diploma or Associates Degree in Nursing required

- BSN preferred

Pay Range

The typical pay range for this role is:

$54,095.60 - $116,760.80

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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 11/26/2024

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