Care Management Associate-OhioRISE - reside in Ohio

Join to apply for the Care Management Associate-OhioRISE - Must reside in Ohio role at CVS Health

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Join to apply for the Care Management Associate-OhioRISE - Must reside in Ohio role at CVS Health

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

The Care Management Associate (CMA) role is a full-time, predominately remote telework position. Some in-state travel (5-10%) may be required for meetings, community engagement, and training. Must possess reliable transportation and be willing. Qualified candidates must reside in Ohio. This position manages enrollment for Children’s Specialty (CS) program including foster, child and family welfare population health members and other programs serving children with special healthcare needs and carries a caseload.

The Care Management Associate supports comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of Wellness Plans to promote effective utilization of healthcare services.

This position promotes/supports quality effectiveness of healthcare services. This is a predominately remote, telework position and qualified candidates must reside in Ohio. Schedule is Monday – Friday, 8am-5pm, standard business hours.

Position Responsibilities

• Responsible for initial review and triage of members.
• Manages population health member enrollment for child and family welfare.
• Manages a low tier member caseload.
• Development of wellness plans, providing community resources, reviewing gaps in care, administering health questionnaires, and other targeted child welfare goals applicable to population health.
• Completes outbound calls to identify and engage appropriate community resources.
• Screens members 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.
• 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.
• Supports the development and implementation of wellness 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, researching information, and assisting in solving problems.
• Adheres to compliance with 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…