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Case Management Specialist – CVS Health

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Position Summary/Mission:  The Case Management Coordinator utilizes critical thinking and judgment to collaborate and inform the case management process, The Case Management Coordinator facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and

education for members through the use of care management tools and resources.

Fundamental Components  

• 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 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 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:

  • 3+ years experience in health-related field

Preferred Qualifications:

  • CRC, CDMS, CRRN, COHN, or CCM certification
  • Medicare and Medicaid experience
  • Managed care experience
  • Experience working with geriatric special needs, behavioral health and disable population
  • Knowledge of assessment, screenings and care planning
  • Bilingual (English/Spanish; English/Creole)

Education:

  • Bachelors Degree or equivalent experience required

Pay Range

The typical pay range for this role is:

$19.52 – $40.10