Job Description

Overview

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. The Aetna Better Health of West Virginia plan has a successful, 26+ year history of partnering with the State to provide West Virginia's Medicaid population with top notch health care coordination and service. The plan also has been chosen to provide care coordination to complex foster care children of the state. Through a strong, localized team, an innovative care management model, and creative provider and community advocacy partnerships, Aetna Better Health of West Virginia has successfully assisted the State in achieving high quality standards and outcomes for the Medicaid population across the state. The health plan truly embodies the commitment of West Virginian's helping West Virginian's. At Aetna Better Health of West Virginia, you can be the very best you can be working with strong teams committed to helping our members and with opportunities for career growth. We will support you all the way!

Position Summary

This is a full-time field teleworker position that requires West Virginia residency. Travel is required 50% of the time or more, in the South region of WV. Candidates MUST RESIDE IN Kanawha, Fayette, Nicholas, Roane, Calhoun, Clay, Webster, Braxton, Gilmer. Field based travel locations may include member homes, residential treatment facilities, group homes, shelters, and detention facilities. Qualified candidates must reside in the region, in one of the following counties:

The Case Manager RN (CM RN) is responsible for telephonically and/or face to face 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 course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration. Services strategies policies and programs are comprised of network management and clinical coverage policies. This position is heavy community-based with some onsite presence at Department of Health and Human Resources (DHHR) offices.

Responsibilities

• Conducts face to face member visits
• Using clinical tools and information/data review, conducts an evaluation of member's needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans.
• 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.
• Assesses information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.
• Reviews prior claims to address potential impact on current case management and eligibility.
• Using a holistic approach assess the need for a referral to clinical resources for assistance in determining 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.
• Utilizes case management processes in compliance with regulatory and company policies and procedures.
• Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
• Effective communication skills, both verbal and written.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.

Required Qualifications

• Must RESIDE IN Kanawha, Fayette, Nicholas, Roane, Calhoun, Clay, Webster, Braxton, Gilmer
• Registered Nurse with current unrestricted West Virginia (WV) license or Registered Nurse with current unrestricted WV or "multi-state privilege" license
• 5+ years' clinical practice experience
• 2+ years' experience with personal computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint, Teams)
• Must possess reliable transportation and be willing and able to travel in the assigned region 50% or more, of the time. Mileage is reimbursed per our company expense reimbursement policy.

Preferred Qualifications

• Medicaid experience.
• Waiver experience
• Foster care experience
• Crisis intervention skills
• Managed care/utilization review experience
• Certified Case Manager (CCM) certification
• Case management experience in an integrated model
• Case management and discharge planning experience
• Familiarity with QuickBase
• BSN degree preferred

Education

• Associate's degree in nursing or nursing diploma required

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,095.00 - $116,760.00

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Benefits

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• 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.

For more information, visit

We anticipate the application window for this opening will close on: 11/27/2025

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

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