Utilizes critical thinking and judgment to collaborate and inform the case management process, in order to facilitate appropriate healthcare outcomes for members by providing care coordination, support and education for members through the use of care management tools and resources.
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
- Provides coaching, information and support to
empower the member to make ongoing independent
medical and/or healthy lifestyle choices.
- Helps member actively and knowledgeably 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.
- 2 years experience in behavioral health, social services or appropriate related field equivalent to program focus required
- Bachelor's degree or non-licensed master level clinician required, with either degree being in behavioral health or human services preferred (psychology, social work, marriage and family therapy, counseling)
- Active and Unrestricted state licensure required (LCSW / LCPC/ LPC / LMFT / LPN / RN)
- Must be comfortable completing Field based travel to meet with Members; 50-75% Travel required in Chicagoland IL and surrounding areas
- Case management and discharge planning experience preferred
- Managed Care experience preferred
- Microsoft Office experience preferred
Bachelor or master's degree prepared in human-services related field. One (1) year of satisfactory program experience may replace one year of college education, at least four (4) years of experience replacing baccalaureate degree
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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