Remote Rn Auditor Jobs in Springfield, IL (NOW HIRING)

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Position Summary

This is a remote work from home role anywhere in the US with virtual training.

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.

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, 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.

• The AHH RN Case manager position requires the nurse to support members across multiple states. A 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+ years’ experience documenting electronically using a keyboard.

• 1+ years’ current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/ Obstetrics experience.

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.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,095.00 - $155,538.00

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.

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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments (https://learn.bswift.com/cvshealth-mainland) .

This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis.

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

CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran — committed to diversity in the workplace.