Analyst, Case Management - Transition of Care

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary
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 lifechanging 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.

Position Summary/Mission

The Case Management Coordinator utilizes critical thinking and judgment to collaborate and inform the case management process, The Case Management Coordinator facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and education for members through the use of care management tools and resources.

Fundamental Components 

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.

Remote Work Expectations

• This a remote role, candidates must have a dedicated workspace free of interruptions.

• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Required Qualifications

• 2+ years experience in behavioral health or social services

• Candidate must have the ability to work 8:00 AM - 5:00 PM in assigned market time zone

• 2+ years of experience with Microsoft Office Applications (Word, Excel, Outlook)

• Candidates must have a dedicated workspace free of interruptions

• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted

Preferred Qualifications

• Case management and discharge planning experience

• Managed care experience

Education

• Bachelor's Degree or non-licensed master level clinician with either degree being in behavioral health or human services preferred (psychology, social work, marriage and family therapy, counseling) or equivalent experience (REQUIRED)

Anticipated Weekly Hours