AnalystCase Mgt
About the position At CVS Health, we are dedicated to bringing our heart to every moment of your health. This role is designed for individuals who are passionate about enhancing human-centric health care in a rapidly changing world. As a member of our team, you will work from home while also being required to travel within Maricopa County, Arizona to visit members. Your primary responsibility will be to coordinate, document, and communicate all aspects of the utilization and benefit management program. You will apply critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for our members, providing care coordination, support, and education through the use of care management tools and resources. In this position, you will conduct comprehensive evaluations of referred members' needs and eligibility, recommending approaches to case resolution and meeting their needs by evaluating their benefit plans and available internal and external programs and services. You will identify high-risk factors and service needs that may impact member outcomes and care planning components, making appropriate referrals as necessary. Your role will also involve coordinating and implementing assigned care plan activities while monitoring the progress of these plans. You will enhance the medical appropriateness and quality of care by using a holistic approach to overcome barriers to meet goals and objectives. This includes presenting cases at case conferences for multidisciplinary review to achieve optimal outcomes and identifying and escalating quality of care issues through established channels. Your negotiation skills will be essential in securing appropriate options and services necessary to meet the member's benefits and healthcare needs. Additionally, you will utilize influencing and motivational interviewing skills to ensure maximum member engagement and promote lifestyle and behavior changes that lead to optimal health. You will provide coaching, information, and support to empower members to make informed medical and lifestyle choices, helping them actively participate in their healthcare decision-making. Monitoring, evaluation, and documentation of care will be conducted in compliance with regulatory and accreditation guidelines and company policies and procedures. This role is crucial in ensuring that our members receive the highest quality of care and support throughout their healthcare journey.
Responsibilities
- Coordinate, document, and communicate all aspects of the utilization/benefit management program.
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- Conduct comprehensive evaluations of referred members' needs and eligibility.
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- Recommend approaches to case resolution and meeting members' needs by evaluating their benefit plans.
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- Identify high-risk factors and service needs that may impact member outcomes and care planning components.
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- Coordinate and implement assigned care plan activities and monitor care plan progress.
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- Present cases at case conferences for multidisciplinary review to achieve optimal outcomes.
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- Identify and escalate quality of care issues through established channels.
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- Utilize negotiation skills to secure appropriate options and services for members.
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- Utilize influencing and motivational interviewing skills to ensure maximum member engagement.
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- Provide coaching, information, and support to empower members to make informed medical and lifestyle choices.
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- Monitor and document care in compliance with regulatory and accreditation guidelines.
Requirements
- 2+ years' Case Management experience working with individuals designated as having a serious mental illness (SMI) and with elderly or physically disabled individuals.
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- Strong organization, collaboration, and time management skills.
Nice-to-haves
- Computer proficiency with Outlook, Windows, and Word.
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- Experience collaborating with medical professionals.
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- Additional Case Management experience.
Benefits
- Full range of medical, dental, and vision benefits.
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- 401(k) retirement savings plan.
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- Employee Stock Purchase Plan.
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- Fully-paid term life insurance plan.
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- Short-term and long-term disability benefits.
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- Numerous well-being programs.
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- Education assistance and free development courses.
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- CVS store discount and discount programs with participating partners.
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- Paid Time Off (PTO) and paid holidays.
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