Remote Utilization Review Rn Jobs in Sterling Heights, MI

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselvesaccountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

• Location: Work From Home - Flexible, Travel Required: 25 - 50% (Wayne and Macomb Counties)

• Schedule: Standard business hours Monday-Friday 8:00am-5:00pm EST

• No evenings, weekends, or major holidays

• 4 day/10-hour schedule available after training

The LTSS RN Case Manager is responsible for comprehensive assessment, care planning, coordination, implementation, and monitoring of Long-Term Services and Supports (LTSS) for dual-eligible Medicare and Medicaid members. This role ensures members receive appropriate waiver and community-based services to promote safety, independence, and improved health outcomes while maintaining regulatory compliance. This position includes in-home visits to complete functional assessments, evaluate eligibility for waiver services, and develop person-centered service plans.
Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand dually eligible members to change lives in new markets across the country. Position Summary/Mission Our Care Managers are frontline advocates for members who cannot advocate for themselves. They are responsible for 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.

• Conduct comprehensive in-home LTSS assessments to determine eligibility for waiver and community-based services.

• Complete and submit required waiver documentation in accordance with state Medicaid and health plan guidelines.

• Develop and implement individualized, person-centered plans of care addressing medical, behavioral, functional, and social determinant needs.

• Apply clinical judgment to identify risk factors, prevent avoidable hospitalizations, and reduce barriers to care.

• Coordinate services across interdisciplinary teams including providers, home health agencies, behavioral health, and community organizations.

• Review claims data, clinical records, and assessment tools to evaluate member needs and benefit utilization.

• Monitor member progress and reassess needs based on changes in condition or level of care.

• Present cases at interdisciplinary team (ICT) meetings and collaborate with supervisors and stakeholders to ensure goal attainment.

• Ensure compliance with Medicaid waiver requirements, CMS regulations, state LTSS guidelines, and company policies.

• Document all case management activities in accordance with regulatory and accreditation standards.

• Educate members and caregivers regarding benefits, services, and available community resources.

• This is a remote role with 25-50% travel required, candidates must have a dedicated workspace free of interruptions.

• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

• Active, unrestricted Registered Nurse (RN) license in the state of Michigan.

• Associate or Bachelor of Science in Nursing (BSN preferred).

• Minimum of 2 years of clinical nursing experience.

• Minimum of 1 year of experience in case management, care coordination, home health, hospice, or long-term care.

• Experience working with Medicare, Medicaid, or dual-eligible populations.

• Knowledge of Long-Term Services and Supports (LTSS), home and community-based services (HCBS), and waiver programs.

• Experience conducting in-home assessments and developing person-centered service plans.

• Strong understanding of social determinants of health and community resource navigation.

• Ability to travel 25-50% within assigned counties, including completion of in-home field visits; reliable transportation is required.

• Proficient in electronic medical records and care management platforms.

• Certified Case Manager (CCM) or willingness to obtain within 2 years.

• Experience in managed care or health plan environment.

• Knowledge of Michigan Medicaid waiver programs and state LTSS regulations.

• Experience presenting cases in interdisciplinary team (ICT) settings.

• Bilingual skills preferred.

• Strong clinical assessment and critical thinking skills

• Excellent communication and member engagement skills

• Ability to manage a high-risk, complex caseload

• Regulatory and compliance knowledge

• Independent decision-making in a remote environment

• 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

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Anticipated Weekly Hours

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Pay Range

The typical pay range for this role is:

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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

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