The Care Manager Specialist is a member of the Care Team. The Care Manager Specialist is responsible for the care management of members that are enrolled in the Dual Special Needs Plan and have limited health conditions. These members are usually stratified as low risk. The Care Manager Specialist will work in conjunction with the Nurse Care Manager, Care Coordinator, Transition of Care (TOC) Coach, and other members of the Care Team to improve the member's health outcomes, address social determinants of health and connect members with community-based organizations. The Care Manager Specialist will assess member's needs as well as gaps in care, communicate with the member's Primary Care Provider (PCP), maintain updated individualized care plans, and participate in Interdisciplinary team meetings. Care Managers will be able to identify members whose needs require clinician involvement and transition members appropriately.

Job Description

Conducts routine care coordination, support, and education through the use of care management resources in order to facilitate appropriate healthcare outcomes for members. Helps implement projects, programs, and processes for Case Management. Applies practical knowledge of Case Management to administer best of class policies, procedures, and plans for the area. Consults with Nurse Case Managers, Supervisors, Medical Directors and/or other members of the Care team using a holistic approach. Presents cases at case conferences to obtain a multidisciplinary review in order to achieve optimal outcomes. Identifies and escalates quality of care issues through established channels. Demonstrates negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs. Delivers 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. Assists in encouraging members to actively participate with their provider in healthcare decision-making. Conducts comprehensive evaluations of referred members' needs/eligibility using care management tools and recommends an approach to case resolution.

Requisition Job Description

This is a full-time telework position with less than 10% travel required.

Hours for this position are Monday-Friday 8:00am - 5:00pm CST.

Program Overview:

Help us elevate our patient care to a whole new level! 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 Dual Eligible Special Needs Plan (DSNP) 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 DSNP to change lives in new markets across the country.

Fundamental Components

• Uses tools and information/data review to conduct an evaluation of member's needs and benefits.
• Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness.
• 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.
• Uses a holistic approach to 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.
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications:

• 3+ years experience in health-related field

Preferred Qualifications:

• CRC, CDMS, CRRN, COHN, or CCM certification
• Medicare and Medicaid experience
• Managed care experience
• Experience working with geriatric special needs, behavioral health, and disabled population.
• Knowledge of assessment, screenings, and care planning
• Bilingual (English/Spanish; English/Creole)

Education:

• Bachelor's degree or equivalent experience require.

Pay Range

The typical pay range for this role is:

$21.10 - $36.78

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 11/25/2024

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