Job DescriptionThis is a remote position with expected travel of 50-75% that will require home visits and possible visits to Nursing Facilities once COVID restrictions are lifted. Territory includes Tarrant, Denton, Wise, Parker, Johnson, or Hood counties. Candidates may reside in one of the listed counties or an adjacent county. Schedule is Monday-Friday, standard business hours, 8:00am-5:00pm CST. Develop, implement, support, and promote health service strategies, tactics, policies, and programs that drive the delivery of quality healthcare to our members. Health service strategies, policies, and programs are comprised of utilization management, quality management, network management, clinical coverage and policies. The position requires advanced clinical judgment and critical thinking skills in order to facilitate appropriate physical, behavioral health, psychosocial wrap around services. The care manager will be responsible for, care planning, direct provider collaboration, and effective utilization of available resources in a cost-effective manner. Strong assessment, writing and communication skills are required.The Case Manager is responsible for conducting face to face visits in the members home utilizing comprehensive assessment tools for members enrolled in Long-Term Services and Support programs. The case manager is responsible for coordinating and collaborating care with the member/authorized representative, PCP, and any other care team participants. The case manager schedules and attends interdisciplinary meetings and advocates on the members behalf to ensure proper and safe discharge with appropriate services in place. The case manager works with the member and care team to develop a care plan and authorizes services in a cost-effective manner within the LTSS benefit. The care manager is responsible for documenting accurately and timely in the member’s electronic health record. This position requires the case manager to use critical thinking skills and the ability to problem solve. The Case Manager will also be expected to mentor new hires once a level of proficiency has been attained in their role.Assessment of Members:- Through the use of care management tools and information/data review, the Case Manager 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 members outcome and care planning components with appropriate referrals.- Coordinates and implements assigned care plan activities and monitors care plan progress.Enhancement of Medical Appropriateness and Quality of Care:- Uses a holistic approach to overcome barriers to meet 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 health.- 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 processes in compliance with regulatory and accreditation guidelines and company policies and procedures.Required Qualifications1+ year(s) clinical experience required.- 1+ year(s) of case management experience required.- 1+ year(s) of experience with personal computers, keyboard and multi-system navigation, and MS Office Suite applications (Outlook, Word, Excel, SharePoint).
COVID RequirementsCOVID-19 Vaccination RequirementCVS 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 QualificationsManaged care experience preferred.- Discharge planning experience preferred.- Experience working with behavioral health members preferred.
EducationBachelor's degree required with either degree being in behavioral health or human services field of study OR non licensed master level clinician preferred, with either degree being in behavioral health or human services field of study.Business OverviewBring your heart to CVS HealthEvery 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.