Qualifying candidates may be eligible for up to a $10,000 sign on bonus.
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the
delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies,
and programs are comprised of utilization management, quality management, network management and clinical coverage
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and
behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination
of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective
Fundamental Components & Physical Requirements include but are not limited to (* denotes essential functions)
• Assessment of Members:
• Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred
member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s
benefit plan and available internal and external programs/services.- Applies clinical judgment to the incorporation of
strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and
resolution of member issues.
- Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical
crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically
indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
• Enhancement of Medical Appropriateness and Quality of Care:- Application and/or interpretation of applicable criteria
and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while
assessing benefits and/or member’s needs to ensure appropriate administration of benefits
- Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to
meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve
- Identifies and escalates quality of care issues through established channels
-Ability to speak to medical and behavioral health professionals to influence appropriate member care.
- Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes 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
-Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify
comprehensive member needs.
• Monitoring, Evaluation and Documentation of Care:-In collaboration with the member and their care team develops
and monitors established plans of care to meet the member’s goals
-Utilizes case management and quality management processes in compliance with regulatory and accreditation
guidelines and company policies and procedures.
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
- 3 or more years of direct clinical practice experience post master’s degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility, hospice/palliative care program/agency.
- Licensed Clinical Social Worker or Licensed Clinical Professional Counselor: (LCSW, LCPC or state equivalent)
- Must be willing to travel 50 - 75% in Madison County IL and surrounding areas once COVID restrictions have been lifted
COVID-19 Vaccination Requirement
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.
- Hospice/palliative care experience preferred
- Advanced care planning experience preferred
- Case management and discharge planning experience preferred
- Managed care/utilization review experience preferred
- Crisis intervention skills preferred
- Knowledge of laws and regulations governing delivery of Medicare services
- Must exercise independent and sound judgment in decision making
- Must be highly organized to manage continuously changing priorities
- Proficiency with computers – (MS Outlook, Excel, PowerPoint, and Word) and must navigate multiple systems simultaneously
Master's Degree required
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.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.