Case Manager Registered Nurse (LTSS) - Field MI (Wayne and Macomb County)

LTSS RN Case Manager

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 ourselves accountable 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.

Position Summary

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.

Key Responsibilities

• 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.

Remote Work Expectations

• 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.

Required Qualifications

• 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 2550% within assigned counties, including completion of in-home field visits; reliable transportation is required.
• Proficient in electronic medical records and care management platforms.

Preferred Qualifications

• 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.

Competencies

• 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

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.

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.