Case Manager Registered Nurse - Field Job at CVS Health (East Orange)

Integrated Care Manager

Responsible for promoting continuity of care through a collaborative process tha...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN
Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications
Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC).

Job Responsibility

Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan
Answer a diverse and high volume of health insurance related customer calls on a daily basis
Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements
Maintain complete and accurate records per department policy
Demonstrate ability to apply plan policies and procedures effectively

Fulltime

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Integrated Care Manager - Adult

Responsible for promoting continuity of care through a collaborative process tha...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN
Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications
Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC)
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate skill in word processing, spreadsheet, and database software
Maintain confidentiality and privacy
Advanced and current clinical knowledge

Job Responsibility

Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan
Answer a diverse and high volume of health insurance related customer calls on a daily basis
Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements
Maintain complete and accurate records per department policy
Demonstrate ability to apply plan policies and procedures effectively

Fulltime

New

Case Manager, Registered Nurse - Field IL

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Cook County

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

March 28, 2026

Requirements

Active and unrestricted Registered Nurse License in Illinois
Minimum 3-5 years clinical practical experience preference required
Minimum 2-3 years CM, discharge planning and/or home health care coordination experience
Must possess reliable transportation and be willing and able to travel up to 75% of the time
Candidates must live in or near: Elk Grove Village, Des Plaines, Park Ridge, Bensenville, Carol Stream, Hanover Park, Itasca. Medinah, Schaumburg, Hoffman Estates, Wooddale Norwood Park, Edison Park
Associates Required, Bachelor's preferred

Job Responsibility

Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate
Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care
Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services
Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status
develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate
Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person
Prepares all required documentation of case work activities as appropriate
Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes
May make outreach to treating physician or specialists concerning course of care and treatment as appropriate
Provides educational and prevention information for best medical outcomes

What we offer

Affordable medical plan options
a 401(k) plan (including matching company contributions)
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
Mileage is reimbursed per our company expense reimbursement policy

Fulltime

Utilization Management Nurse

The Utilization Management Nurse supports the case management department by prov...

Location

United States , Madera

Salary:

53.00 - 82.00 USD / Hour

Valley Children's Healthcare

Expiration Date

Until further notice

Requirements

Associates Degree Nursing (required)
Bachelors Degree Nursing or related field (preferred)
RN - Registered Nurse License - CA-BRN - California Board of Registered Nursing (required)
Minimum three (3) years Full time equivalent RN experience in an acute care hospital. (required)
Pediatric experience and experience in Case Management and/or Utilization Review. (preferred)
Knowledge of UM regulations
Knowledge of private and public payer reimbursement practices and procedures
Excellent organizational and communication skills and ability to work with a variety of health care professionals
Ability to work independently
Computer Skills Proficiency with word processing, spreadsheets and database software

Job Responsibility

Supports the case management department by providing a variety of utilization management functions including but not limited to daily screening of patient admission relative to specified criteria
Active involvement in denial management
Acting as a resource to staff regarding clinical criteria
Communication with payors to address concerns and other duties as assigned
Work collaboratively with the Utilization Nurse Program Coordinator to ensure compliance with regulatory, organizational and department requirements

Parttime

Care Manager, Registered Nurse – Field

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Camden County

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

April 01, 2026

Requirements

Candidate must reside close to or within Camden County, New Jersey
Candidate must have an active and unrestricted Registered Nurse (RN) license in New Jersey
Candidate must be willing and able to travel 25-50% of their time using your own vehicle to meet members face to face in their assigned area
3+ years of clinical practice experience
Associate's Degree in Nursing (REQUIRED)

Job Responsibility

Assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness.
Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness.
Uses clinical tools and information/data review to conduct an evaluation of member's needs and 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.
Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality.
Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members.
Collaborates with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences
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 conversation.

What we offer

Affordable medical plan options
a 401(k) plan (including matching company contributions)
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.
Paid time off
flexible work schedules
family leave
dependent care resources
colleague assistance programs
tuition assistance

Fulltime

New

Case Manager Registered Nurse - Field MI

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Lansing

Salary:

60522.00 - 129615.00 USD / Year

CVS Health

Expiration Date

April 02, 2026

Requirements

Registered Nurse with active MI state license in good standing
Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually
Ability to travel within a designated geographic area for in-person case management activities as directed by Leadership and/or as business needs arise
Excellent analytical and problem-solving skills
Effective communications, organizational, and interpersonal skills.
Ability to work independently
Effective computer skills including navigating multiple systems and keyboarding
Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint
Associate's Degree required.

Job Responsibility

Visiting members in their homes to evaluate for appropriateness for waiver services, writing the waiver and submitting for approval.
Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness.
Uses clinical tools and information/data review to conduct an evaluation of member's needs and 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.
Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality.
Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members.
Collaborates with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences
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 conversation.

What we offer

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.

Fulltime

Nurse Case Manager

Client is looking to onboard a Nurse Case Manager, in a contingent role. We are ...

Location

United States

Salary:

Not provided

Revel IT

Expiration Date

Until further notice

Requirements

Minimum of a registered nurse degree with IL licensure
Must have at least one year as a worker’s compensation case management nurse
Must have two or more years of clinical experience in orthopedics, occupational medicine or internal medicine
Must have experience with: Worker’s compensation
Official disability guidelines site
Microsoft Teams and Outlook

Job Responsibility

Complete early medical management assessment and intervention on claims requiring medical treatment
Contact injured workers and medical providers to obtain necessary information
Apply knowledge, experience and evidence-based guidelines to evaluate claims and provide a proactive action plan
Perform essential medical case management activities assessment, planning, implementation, monitoring and evaluation within accepted treatment guidelines
Identify and monitor claims for task assignments to field case managers
Address medical cost containment through utilization management, collaboration with providers and assessing network resources

Fulltime

Case Manager Registered Nurse - Field

CVS Health

Location:
United States , East Orange

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
March 04, 2026

Expiration:
March 31, 2026

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