CVS Health
Position Summary
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) supports comprehensive coordination of medical services that include intake and outgoing calls for medical services. The CMA works closely with both the case management team and utilization management team.
Responsibilities
Must live/work in PST.
Review eligibility and benefits, open pre‑certification cases, and either approve or send to nursing staff for review.
Initial review and triage of Care Team tasks.
Identify principal reason for admission, facility, and member product to correctly apply intervention assessment tools.
Screen patients 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.
Monitor non‑targeted cases for entry of appropriate discharge date and disposition.
Identify and refer outlier cases (e.g., length of stay) to clinical staff.
Identify triggers for referral into Aetna’s Case Management, Disease Management, Mixed Services, and other Specialty Programs.
Utilize Aetna systems to build, research and enter member information, as needed.
Support the development and implementation of care plans.
Coordinate and arrange 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.
Promote communication, both internally and externally, to enhance effectiveness of medical management services (e.g., health care providers and health care team members).
Perform non‑medical research pertinent to the establishment, maintenance, and closure of open cases.
Provide support services to team members by answering telephone calls, taking messages, researching information, and assisting in solving problems.
Adhere to compliance with PM policies and regulatory standards.
Maintain accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Protect confidentiality of member information and adhere to company policies regarding confidentiality.
Assist in the research and resolution of claims payment issues.
Support administration of 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 and procedures.
Required Qualifications
Minimum of 6 months of call center experience.
Must live/work in PST.
Preferred Qualifications
Effective communication, telephonic, and organization skills.
Familiarity with basic medical terminology and concepts used in care management.
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Computer literacy to navigate through internal/external computer systems, including Excel and Microsoft Word.
Education High School Diploma or equivalent experience.
Anticipated Weekly Hours 40 hours
Time Type Full-time
Pay Range The typical pay range for this role is $18.50 – $31.72 per hour. This range represents the base hourly rate for all positions in the job grade within which this position falls. The actual base salary offer depends on experience, education, geography, and other factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range.
Benefits We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to competitive wages, our great benefits include affordable medical plan options, a 401(k) plan (including matching company contributions), an employee stock purchase plan, no‑cost wellness programs (screenings, tobacco cessation, weight management, counseling, financial coaching) and benefit solutions such as paid time off, flexible schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access, and many other benefits depending on eligibility.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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The Care Management Associate (CMA) supports comprehensive coordination of medical services that include intake and outgoing calls for medical services. The CMA works closely with both the case management team and utilization management team.
Responsibilities
Must live/work in PST.
Review eligibility and benefits, open pre‑certification cases, and either approve or send to nursing staff for review.
Initial review and triage of Care Team tasks.
Identify principal reason for admission, facility, and member product to correctly apply intervention assessment tools.
Screen patients 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.
Monitor non‑targeted cases for entry of appropriate discharge date and disposition.
Identify and refer outlier cases (e.g., length of stay) to clinical staff.
Identify triggers for referral into Aetna’s Case Management, Disease Management, Mixed Services, and other Specialty Programs.
Utilize Aetna systems to build, research and enter member information, as needed.
Support the development and implementation of care plans.
Coordinate and arrange 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.
Promote communication, both internally and externally, to enhance effectiveness of medical management services (e.g., health care providers and health care team members).
Perform non‑medical research pertinent to the establishment, maintenance, and closure of open cases.
Provide support services to team members by answering telephone calls, taking messages, researching information, and assisting in solving problems.
Adhere to compliance with PM policies and regulatory standards.
Maintain accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Protect confidentiality of member information and adhere to company policies regarding confidentiality.
Assist in the research and resolution of claims payment issues.
Support administration of 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 and procedures.
Required Qualifications
Minimum of 6 months of call center experience.
Must live/work in PST.
Preferred Qualifications
Effective communication, telephonic, and organization skills.
Familiarity with basic medical terminology and concepts used in care management.
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Computer literacy to navigate through internal/external computer systems, including Excel and Microsoft Word.
Education High School Diploma or equivalent experience.
Anticipated Weekly Hours 40 hours
Time Type Full-time
Pay Range The typical pay range for this role is $18.50 – $31.72 per hour. This range represents the base hourly rate for all positions in the job grade within which this position falls. The actual base salary offer depends on experience, education, geography, and other factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range.
Benefits We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to competitive wages, our great benefits include affordable medical plan options, a 401(k) plan (including matching company contributions), an employee stock purchase plan, no‑cost wellness programs (screenings, tobacco cessation, weight management, counseling, financial coaching) and benefit solutions such as paid time off, flexible schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access, and many other benefits depending on eligibility.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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