Position Summary

Provide comprehensive healthcare management to facilitate delivery of

appropriate quality healthcare, promote cost effective outcomes and

improve program/operational efficiency involving clinical issues.

Support comprehensive coordination of medical services including Care

Team intake, screening and supporting the implementation of care plans to

promote effective utilization of healthcare services. Promotes/supports

quality effectiveness of Healthcare Services.

Responsible for initial review and triage of Care Team tasks.

Identifies principle reason for admission, facility, and member product to

correctly apply intervention assessment tools.

Screens patients using targeted intervention business rules and processes

to identify needed medical services, make appropriate referrals to medical

services staff and coordinate the required services in accordance with the

benefit plan.

Monitors non-targeted cases for entry of appropriate discharge date and

disposition.

Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff.

Identifies triggers for referral into Aetna's Case Management, Disease

Management, Mixed Services, and other Specialty Programs.

Utilizes eTUMS and other Aetna systems to build, research and enter

member information, as needed.

Support the Development and Implementation of Care Plans. Coordinates

and arranges for health care service delivery under the direction of nurse or

medical director in the most appropriate setting at the most appropriate

expense by identifying opportunities for the patient to utilize participating

providers and services.

Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g.,health care providers, and health care team members respectively)

Performs non-medical research pertinent to the establishment,

maintenance and closure of open cases

Provides support services to team members by answering telephone calls,

taking messages, researching information and assisting in solving

problems.

Adheres to Compliance with PM Policies and Regulatory Standards.

Maintains accurate and complete documentation of required information

that meets risk management, regulatory, and accreditation requirements.

Protects the confidentiality of member information and adheres to company

policies regarding confidentiality.

May assist in the research and resolution of claims payment issues.

Supports the administration of the hospital care, case management and

quality management processes in compliance with various laws and

regulations, URAQ and/or NCQA standards, Case Management Society of

America (CMSA) standards where applicable, while adhering to company

policy and procedures. (*)

Required Qualifications

Effective communication, telephonic and organization skills.

Familiarity with basic medical terminology and concepts used in care

management.

Strong customer service skills to coordinate service delivery including

attention to customers, sensitivity to issues, proactive identification and

resolution of issues to promote positive outcomes for members.

Computer literacy in order to navigate through internal/external computer

systems, including Excel and Microsoft Word.

Ability to effectively participate in a multi-disciplinary team including internal

and external participants.

Call Center Experience

Preferred Qualifications

Medical terminology

Education
HS Diploma

Pay Range

The typical pay range for this role is:

$18.50 - $31.72

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: 11/08/2024

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