Role Description The RN Case Manager primary responsibility is to create, implement, and monitor treatment plans to assist patients/members in meeting their healthcare goals. You would use knowledge of healthcare and social services to assess needs and provide interdisciplinary care options in treatment planning for the member. This would include understanding the member's healthcare benefits and healthcare best practices needed for effective treatment planning. - Case Management process includes assessing the member’s health status and care coordination needs. - Contact with patient, family, physicians, additional health care providers, and community resources. - Identification of alternative treatment plans, which would have to be approved by all parties. - Assessment of the clinical status and resultant sequela to coordinate the most appropriate service. - Identification of services, resources, providers, and facilities that could best serve members. - Development and implementation of Case Management goals, both short and long term, with documented care plans. - Utilize technology/resources to evaluate the cost-effectiveness of the elected treatment plan. - Accurate and timely reporting as deemed appropriate by each client member. - Medical record review to determine medical necessity of requested services. - Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions. Qualifications - 5+ years related work experience with a professional background in clinical nursing and patient assessment. - Bilingual in Spanish. - Related Bachelor’s degree or additional related equivalent work experience. - Graduate of an accredited school of nursing. - RN - Registered Nurse - State Licensure. - Compact State Licensure in good standing. - Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices. - Ability to collaborate with cross-operational areas within the organization. Requirements - (CCM) Certified Case Manager preferred. - New York state Registered Nurse licensure preferred. - Prior experience in utilization management or case management preferred, preferably within the managed care environment. - Intensive care or higher-acuity patient experience preferred. - Knowledge of managed care in a self-funded employer population is preferred. - Ability to identify problems such as underutilization or overutilization of services. - Ability to promote and maintain quality care through analysis. Benefits - Medical, dental, vision, life and global travel health insurance. - Income protection benefits: life insurance, Short- and long-term disability programs. - Leave programs to support personal circumstances. - Retirement Savings Plan includes employer contribution and employer match. - Paid time off, volunteer time off, and 11 holidays. - Additional voluntary benefits available and a comprehensive wellness program. General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

The UM Clinical Reviewer Senior Analyst promotes quality and cost-effective medical services through clinical review, applying Cigna clinical policies, national guidelines, and decision-support tools to determine authorizations. The role ensures timely completion of reviews to meet regulatory and contractual requirements while representing Cigna professionally. Core Responsibilities: - Conduct utilization management reviews for medical necessity, appropriateness, and benefit coverage. - Apply Cigna medical policies, MCG, ASAM, URAC standards, and clinical judgment. - Identify cases requiring physician review and coordinate with Medical Directors. - Initiate Case Management referrals as appropriate. - Maintain compliance with HIPAA, regulatory rules, and internal quality standards. - Participate in team meetings, quality audits, training, and workflow improvements. - Support departmental initiatives, documentation accuracy, and performance metrics. Qualifications: - Registered Nurse (RN) with multistate license in good standing. - BSN preferred. - Minimum 3 years RN experience in managed care, UM, or prior authorization preferred. - Previous in-patient or outpatient experience preferred. - Strong analytical, communication, and decision-making skills. - Proficiency with Windows, Word, care management platforms, and documentation systems. - Ability to manage multiple tasks, meet deadlines, and adapt to a fast-paced environment. Competencies - Clinical Judgment & Decision Making - Regulatory & Policy Compliance - Communication & Collaboration - Customer-focused Service Delivery - Time & Workload Management If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here. About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

REMOTE OPPORTUNITY! BAYADA Home Health Care is seeking a remote Clinical Support Specialist (RN required) for our Home Health Senior Care team. The ideal candidate will be a Registered Nurse in North Carolina. Do you want to be part of providing care with the highest professional, ethical, and safety standards? Do you want to use your skills to make a difference in people’s lives? We’re BAYADA Home Health Care—a leading home health care company—and we believe that our clients and their families deserve home health care delivered with compassion, excellence, and reliability. Your important work will help ensure that our clients come first and that our BAYADA caregivers have the support they need to be successful. In this growing and dynamic environment, we offer exciting career paths for nurses like you. Responsibilities for a Clinical Support Specialist: - Review Oasis and Homecare Homebase 485 documentation - Applies knowledge and experience with implementation of standardized QI surveys and mentoring, orienting and educating Clinical Managers/Leaders. - Serves as a general clinical resource to expand into mentoring, identifying and recommending changes in agency policies and practices, and assisting in development and/or implementation of new policies, procedures, programs and services. Qualifications for a Clinical Support Specialist: - Registered Nurse (RN) with 2 or more years of experience as an RN in North Carolina. - Experience using Oasis required. - Compact License Required (can practice in NC, and FL) Why you'll love BAYADA: - Award- Winning Workplace- Proud to be recognized by Newsweek as a Best Place to Work for Diversity, reflecting our commitment to creating an inclusive, supportive environment. - Impactful Work- Make a meaningful impact in the lives of thousands of clients in the community - Weekly Pay- Consistent weekly paychecks to keep your finances on track. - Comprehensive Benefits- Medical, dental, vision, and more-- we've got you covered - Work- Life Balance- Enjoy a Monday-Friday, 8:30 AM- 5:00 PM schedule. - Career Growth- Advancement opportunities to help you grow in your career. - Nonprofit Organization- As a mission-driven nonprofit, BAYADA offers eligibility for the Pubic Service Loan Forgiveness (PSLF) Program to help reduce student loan debt. Join BAYADA and be a part of a team dedicated to providing exceptional home health care to our clients. #LIRX #JoinBayada-RX As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.

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 Health Plan Clinical Advisor is a client facing role that manages the clinical relationship by influencing multiple key decision makers at a health plan. These include the health plan’s pharmacy support team, pharmacists, medical directors, CMO as well as other senior health plan leaders. The Health Plan Clinical Advisor should be able to manage at least 2 and up to 4 market segments for any particular client (Medicare, Medicaid, Exchange, or Commercial). The Health Plan Clinical Advisor is responsible for proactively managing the clinical relationship alongside the business lead (SAE/SAD) to understand and drive each of their client’s priorities, financial targets, clinical goals and other commitments to their leadership. The Health Plan Clinical Advisor will analyze and evaluate the client’s data and competitive marketplace conditions and forces to develop and execute a comprehensive business plan that supports the client’s short- and long-term profitability and growth strategies. Key components being eliminating waste, reducing inefficiency and maximizing impact to manage chronic disease. This includes: - Collaborating with clients on analysis of their key marketplace competitors and those products and services. - Consulting with and recommending standard and custom formulary options and utilization management edits. - Collaborating with internal partners to develop or modify custom programs or formularies that meet the unique needs of health plan clients. - Collaborating with CVSH trade partners on formulary strategies to maximize rebate value and drives lowest net cost. - Consulting with and recommending utilization management programs or other clinical programs to a client. - Consulting with and recommending specialty drug strategy options. - Consulting with ANCS, to utilize clinical and financial reports to evaluate current benefit design and provide recommendations to clients on any opportunities. - Consulting and Influence clients on current drugs trends, drug pipeline, as well as proactive monitoring of FWA trends. - Consulting and influencing clients on a regular basis, developing a trusted consultative partnership that drives client loyalty and fulfills both clients commitments and CVSH goals. - Conducting Provider and Member outreach as needed for client communications. The Health Plan Clinical Advisor will consult with and advise the Clinical Benefits Pharmacist, and or other members of the Benefits and Operations teams so that those teams can timely and accurately implement a client’s requirements. The Health Plan Clinical Advisor will collaborate with CVSH internal partners to ensure compliance to any federal, state or local regulatory requirements that impact formulary, UM and or clinical programs and consult with any clients on the impact that such requirements might have on their plan. The Health Plan Clinical Advisor is accountable for ensuring that CVSH meets or exceeds any health plan client value targets each year and is responsible for proactively collaborating with business leads to identify client value and then provide consultative advice and follow up with the client on such recommendations. Consultative advice may include recommendations for program pilots, modification to existing CVSH programs to support the unique needs of the health plan segment and marketplace and/or how CVSH as an enterprise can support health plans through our open source model. The Health Plan Clinical Advisor is responsible for ensuring they meet or exceed their personal and departmental client satisfaction scores target each year. This position can be based out of a CVS Health Corporate Hub or can work remotely/work from home within the United States. Clinical Advisors must have the ability to travel up to 50% of the time as required to meet business needs, with the ideal candidate residing near a major airport. Required Qualifications 3+ years of managed care Pharmacist experience and/or 1 year of Managed Care Residency program. - Active pharmacist license that is in good standing. - Demonstrated experience in a client-facing role within the managed care environment - Demonstrated understanding of and experience with utilization management trends and programs within the managed care environment - Highly organized, detail oriented, proficient analytical ability with effective listening & presentation skills are required. Preferred Qualifications - 3-5 years of experience supporting Pharmacy Benefit Management (PBM) clients or within a health plan. - Experience in all market segments (Medicare, Medicaid, Exchange and Commercial) - Expertise in Utilization Management, Formulary Management and Clinical Products - Proven leadership skills. - Strong business acumen. - Commitment to client service and relationship building. - Experience implementing template and/or customized clinical programs. - Knowledge of PBM adjudication engine and other systems leveraged in support of clients. - AMCP Fundamentals of Managed Care Pharmacy Certificate or similar professional advancement. Education Bachelor of Science Pharmacy or PharmD. Active, unrestricted pharmacist licensure required Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $110,925.00 - $249,600.00 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. 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 https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/31/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.