Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
The Care Management Associate (CMA) supports comprehensive coordination of medical services that include intake and outgoing calls for medical services. We work closely with both case management team and utilization management team.
The Care Management Associate will review eligibility and benefits and open pre-certification cases and either approve or send to nursing staff for review.
The Care Management Associate role include:
-Responsible for initial review and triage of Care Team tasks.
-Identifies principal reason for admission, facility, and member product to correctly apply intervention assessment tools.
-Screen 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 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 Minimum of 6 months of call center experience required. Preferred 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 to navigate through Internal/external computer systems, including Excel and Microsoft Word.
High School Diploma or equivalent experience
The typical pay range for this role is:
$18.50 - $35.29
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 jobs.CVSHealth.com/benefits
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.