Job Description

Employment Type: Full time

Location Type: Fully remote in the USA

Salary: [Not Specified]

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Position Overview

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.

This role 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.

Shift: Monday-Friday standard business hours. No weekends and no holidays.

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Responsibilities

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 a 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 a 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 knowledgeably 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.

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Required Qualifications

• 3 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.
• 3 years knowledge of mental health and substance abuse disorders.
• 3 years experience talking, speaking on the telephone, and typing at the same time.
• 3 years experience using Motivational Interviewing and good technological skills.
• Valid unrestricted independent p[License/Certification details not fully specified]

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Company Information

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.

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Application Instructions

[Not Specified]