Case Manager Registered Nurse - Single Point of Contact - Work at Home

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. And we do it all with heart, each and every day.

Aetna is hiring a Single Point of contact (Dedicated Clinical Advocate) to support one of our premier healthcare clients. In this role, you will drive member engagement, optimize care delivery, and influence benefit strategies. Acting as a trusted advisor, you will connect members to resources, remove barriers to care, and deliver measurable improvements in health outcomes.

Serve as a primary contact for members, guiding them through benefits and care options for a seamless experience. Promote holistic well-being through initiatives focused on physical and mental health. Proactively engage high-cost claimants and frequent ER users, educating on appropriate care settings and facilitating PCP connections. Monitor out-of-network utilization and educate members on cost-effective, in-network care options. Coach members with chronic conditions, set personalized health goals, and connect them to Aetna One Flex Nurse for ongoing support. Act as client lead with case management teams, aligning care strategies with client culture and goals. Ensure smooth Transition of Care for new members and refer to specialized programs (e.g., 2nd MD, Health Advocate, Lantern, EAP). Leverage data analytics to identify gaps in care and design targeted outreach strategies to close those gaps. Review appeals and denials to identify policy improvement opportunities that remove barriers to care. Analyze utilization data and collaborate with account teams to develop actionable clinical and benefit strategies. Lead high-cost claimant reviews and implement targeted population health initiatives Partnering with the plan sponsor and Aetna account team to address concerns, resolve issues, and manage high-cost claimants in collaboration with external vendors as needed. Conducting proactive outreach to targeted populations to support care coordination and improve health outcomes. Serving as the direct contact for plan escalations and benefit-related inquiries from members or the plan sponsor. Educating internal and external stakeholders on narrow network utilization and home-host steerage strategies. Collaborating with Utilization Management on complex cases to ensure seamless care transitions. Reviewing reports from the account team and CPC to identify outreach opportunities, support domestic steerage, and analyze data for improved member engagement. Participating in annual utilization reviews with the account team and key plan sponsor stakeholders. Supporting special projects as assigned by HBS Leadership, the Account Team, or the Plan Sponsor. Traveling to plan sponsor healthcare facilities (approximately 10–15%) for annual meetings, collaboration sessions, or open enrollment events as requested.