Job Description

Job Description

Job Description

Description:

Hiring needs for the following locations:

LOCATION NEEDED WILL BE: Ellis County

This will be a full-time telework role in Kansas, however, will require 50-75% travel for face-to-face visits in assigned area once COVID restrictions are lifted. Schedule is Monday-Friday, standard business hours. Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies. Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and
education for members through the use of care management tools and resources.

Evaluation of Members:
- Through the use of care management tools and information/data review, conducts comprehensive
evaluation of referred member's needs/eligibility and recommends an approach to case resolution and/or
meeting needs by evaluating member's benefit plan and available internal and external programs/services.
- Identifies high risk factors and service needs that may impact member outcomes and care planning
components with appropriate referral to clinical case management or crisis intervention as appropriate
- Coordinates and implements assigned care plan activities and monitors care plan progress.
Enhancement of Medical Appropriateness and Quality of Care:
- Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health
programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to
obtain multidisciplinary review in order to achieve optimal outcomes.
- Identifies and escalates quality of care issues through established channels.
- Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's
benefits and/or healthcare needs.
- Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and
promote lifestyle/behavior changes to achieve optimum level of health.
- Provides coaching, information and support to empower the member to make ongoing independent
medical and/or healthy lifestyle choices.
- Helps member actively and knowledgably participate with their provider in healthcare decision-making.
Monitoring, Evaluation and Documentation of Care:
- Utilizes case management and quality management processes in compliance with regulatory and
accreditation guidelines and company policies and procedures

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Additional Details

• Duties : Evaluation of Members: - Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member's needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services. - Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate - Coordinates and implements assigned care plan activities and monitors care plan progress. Enhancement of Medical Appropriateness and Quality of Care: - Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes. - Identifies and escalates quality of care issues through established channels. - Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's View Job Posting Details CVS Health and/or one of its affiliates. Confidential and proprietary. All Rights Reserved 02:45 PM 12/15/2023 Page 2 of 3 benefits and/or healthcare needs. - Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health. - Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. - Helps member actively and knowledgably participate with their provider in healthcare decision-making. Monitoring, Evaluation and Documentation of Care: - Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

• Experience : 1+ year(s) behavioral health, social services, or human services field. -Willing and able to travel up to 50%-75% locally to meet members face to face - Must have reliable transportation .

• Preferred Qualifications : - Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel is strongly preferred. - Case management and discharge planning experience preferred - Managed Care experience preferred -1-year Experience in Home and Community based services (HCBS) waiver.
• Position Summary : Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues
• Education : Bachelor's degree or non-licensed master level clinician required, with either degree being in behavioral health or human services preferred (psychology, rehabilitation, social work, marriage and family therapy, counseling).

• What days & hours will the person work in this position? List training hours, if different. : M-F 8-5
• Type of Start : Individual starts
• Is this an in-person, patient-facing role? : Yes
• Onsite Requirements : Fully remote (never coming onsite)

QualificationAssessmentMust HaveCVS Caremark Requirements

Prior CVS/Aetna work experience?

No

Verifyable High School Diploma or GED Required

Yes

Job Tags

Full time, Work experience placement, Work from home, Monday to Friday,

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