Analyst, Case Management- Field- Mountain Health Promise

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Business Overview:

The Aetna Better Health of West Virginia plan has a successful, 26+ year history of partnering with the State to provide West Virginia’s Medicaid population with top notch health care coordination and service. The plan also has been chosen to provide care coordination to complex foster care children of the state. Through a strong, localized team, an innovative care management model, and creative provider and community advocacy partnerships, Aetna Better Health of West Virginia has successfully assisted the State in achieving high quality standards and outcomes for the Medicaid population across the state. The health plan truly embodies the commitment of West Virginian’s helping West Virginian’s. At Aetna Better Health of West Virginia, you can be the very best you can be working with strong teams committed to helping our members and with opportunities for career growth. We will support you all the way!

Position Summary:

This is a full-time field teleworker position that requires West Virginia residency. Travel is required 50% of the time or more, in the Northern region of WV. Field based travel locations may include member homes, residential treatment facilities, group homes, shelters, and detention facilities. Qualified candidates must reside in the region, in one of the following counties: Barbour, Brooke, Doddridge, Hancock, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants, Ritchie, Taylor, Tyler, Upshur, Wetzel

Utilizes critical thinking and judgment to collaborate and inform the case management process, to facilitate appropriate healthcare outcomes for members by providing care coordination, support, and education for members through the use of care management tools and resources.

Schedule is Monday-Friday standard business hours. No nights, no weekends, and no holidays.

Evaluation of Members:
-Through the use of care management tools and information/data review, 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 member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. - Coordinates and implements assigned care plan activities and monitors care plan progress.

Enhancement of Medical Appropriateness and Quality of Care:
- Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review 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 knowledgably participate with their provider in healthcare decision-making.

Monitoring, Evaluation and Documentation of Care:
- Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications:
-2 years’ experience in behavioral health, social services, or appropriate related field equivalent to program focus
-West Virginia resident residing in one of the following counties: Barbour, Brooke, Doddridge, Hancock, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Pleasants, Ritchie, Taylor, Tyler, Upshur, Wetzel
-Must possess reliable transportation and be willing and able to travel in the assigned region 50% or more of the time. Mileage is reimbursed per our company expense reimbursement policy.
- 2+ years of experience with personal computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint, Teams)

Preferred Experience:

- Medicaid experience

- Waiver experience

- Foster care experience

- Crisis intervention skills

- Managed care/utilization review experience

- Case management and discharge planning experience

- Familiarity with QuickBase

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