Job Description Qualifying candidates may be eligible for up to a $7,000 sign on bonus.
Family Summary/Mission 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 and policies. Position Summary/Mission 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 outcomes. Fundamental Components & Physical Requirements include but are not limited to (* denotes essential functions) â¢ Assessment of Members: â¢ Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred memberâ™s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating memberâ™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. â¢ 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 memberâ™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 optimal outcomes - 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. â¢ 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 memberâ™s goals -Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Required Qualifications - 3 or more years of direct clinical practice experience post masterâ™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 Winnebago 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.
Preferred Qualifications - 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 â“â¯(MS Outlook, Excel, PowerPoint, and Word) and must navigate multiple systems simultaneously
Education Master's Degree required
Business Overview 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.
Combining CVS Health and Aetna was a transformative moment for our company and our industry, establishing CVS Health as the nation’s premier health innovation company. Through our health services, insurance plans and community pharmacists, we’re pioneering a bold new approach to total health. As a CVS Health colleague, you’ll be at the center of it all. At CVS Health, we work every day to help people on their path to better health. Never has it been more important for us to deliver on our purpose to our valued customers, patients, members, and employees. With a presence in communities across the country, CVS Health colleagues are and will continue to be a critical piece of the country’s health care solution. The health and safety of our employees, patients, customers, and members is our top priority as we face the impact of COVID-19 together. If you would like to learn about the actions we are taking as a company as we learn more about COVID-19 and its spread, we encourage you to visit our COVID-19 resource center at https://cvshealth.com/covid-19 We offer a diverse work experience that empowers colleagues for career success. In addition to skill and experience, we also seek to att...ract and retain colleagues whose beliefs and behaviors are in alignment with our core values of collaboration, innovation, caring, integrity and accountability. CVS Health is an equal opportunity/affirmative action employer. Gender/Ethnicity/Disability/Protected Veteran – we highly value and are committed to all forms of diversity in the workplace. 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. We comply with the laws and regulations set forth in the following EEO is the Law Poster: EEO IS THE LAW and EEO IS THE LAW SUPPLEMENT. Please note that we only accept applications for employment via this site. We provide reasonable accommodations to qualified individuals with disabilities. If you need to request an accommodation, a qualified interpreter, written information in other formats, translation or other services, please contact our Advice and Counsel Reasonable Accommodations team by emailing Advice and Counsel Reasonable Accommodations team or calling 877-805-9511. If technical issues are preventing you from applying to a position, contact Kenexa Helpdesk at 1-855-338-5609 or email@example.com. For technical issues with the Virtual Job Tryout, contact the Modern Hire Help Desk at 1-877-451-1695 or firstname.lastname@example.org.