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.Position Summary This Associate Manager, Clinical Health Services position is with Aetna's Long-Term Services and Supports (LTSS) team and is a fully remote opportunity.Designs and implements Clinical Health medical services, leveraging industry-proven procedures and best practices. Assists with clinical Health Service programs, procedures, and services.What you will do:
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- Owns responsibility for the oversight of Long-Term Services and Supports (LTSS) and Waiver healthcare case management staff, including progressing initiatives for high-performing health service teams.
- Works closely with functional Health Services managers in order to ensure ongoing consistency and accuracy in clinical interventions supporting current members.
- Takes accountability for completing tasks aimed to successfully achieve the financial, operational, and quality objectives of the work area.
- Functions as a key resource to healthcare members for governmental, state, local, and legal initiatives Medicare acts and regulations.
- Assists in implementing and sustaining action plans, initiatives, and strategies for Clinical Health Services policies and procedures.
- Provides application expertise to Health Services account managers as needed, to aid in the retention of existing clients by improving team member use of healthcare resources and tools.
- Partners with patient resources and divisional management, Clinical Education, and other key departments to assist in the evaluation of performance initiatives, subsequently recommending appropriate training to positively impact outcomes.
- Works to implement effective Clinical Health Services change management plans when new initiatives are rolled out or enhanced by upper management.
- Facilitates regular staff meetings to ensure all team members are fully versed on ongoing as well as new work area policies, procedures, and expectations.
- This role is essential for monitoring, training, oversight and compliance for the Utilization Management Team which is responsible for the turnaround times as per the NY MLTC contract for service decision reviews, notice of actions, approval letters, standard authorizations and expedited authorizations.
- This position is reports Performance Guarantees (PG's) to the CEO and Compliance officer on a monthly basis through MOR. Turnaround times for standard and expedited authorizations as well as timely member notifications for initial adverse determinations. This position also works closely with the Medical Director to ensure compliance and accuracy of service decision reviews and applying medical necessity to the service requests. This position ensures compliance and accuracy through (IRR) Interrater reliability of the UM clinicians to maximize the Medicare guidelines on both Federal and State side.
- 3-5 years work experience in Utilization Management, preferably in LTSS
- 3-5 years' work experience with at least 1 year in a leadership position
- Requires RN License, and specialized knowledge and expertise from entry to experienced level
- Advanced problem solving and decision making skills.
- Advanced knowledge of medical terminology.
- Advanced collaboration and teamwork skills.
- Advanced growth mindset skills (agility and developing yourself and others).
- Advanced skills in execution and delivery (planning, delivering, and supporting).
- Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.
- Advanced digital literacy skills.
- Bachelors in Nursing Degree Required
40Time Type
Full timePay Range
The typical pay range for this role is:$88,374.00 - $190,344.00This 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 peopleWe 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.