A1A Care Management Representative

CVS Pharmacy


Job Description
Job DescriptionThis position is temporarily Work From Home due to COVID 19.What is A1A Aetna One Advocate is Aetna's premier service and clinical offering for Aetna nation-wide and creates industry-leading solutions for our customers and members. The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services. The mission of this model is designed to meet each member at every aspect of their health care journey. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members' needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. This is an exciting time to join Aetna a CVS Health company in our journey to change the way healthcare is delivered today. We are health care innovators.Aetna One Advocate is Aetna's premier service and clinical offering for Aetna nation-wide and creates industry-leading solutions for our customers and members. The model is a fully integrated population health and customer service solution for large plan sponsors high-touch, high-tech member advocacy service which combines data-driven processes with the expertise of highly trained clinical and concierge member services. The mission of this model is designed to meet each member at every aspect of their health care journey. Our embedded customer-dedicated service and clinical pods allow maximization of inbound and outbound touchpoints to solve members' needs and create behavior change. Our data analytics, white-glove service and end-to-end ownership of member support creates a trusted partner in health. This is an exciting time to join Aetna a CVS Health company in our journey to change the way healthcare is delivered today. We are health care innovators.Required QualificationsSupport comprehensive & proactive coordination of medical services through direct member outreach that drives partnership in developing holistic plans of care and leads to influencing a member's effective use of programs, tools, and resources. Promotes/supports quality effectiveness of Healthcare Services Conducts proactive, targeted member outreach to drive utilization of healthcare services aligned to member-specific health ambitions Prepare for outreach by researching previous calls and actions, collaborating with clinical staff to ensure most impactful service delivery, and documenting in ATV system as appropriate Educate and influence members on use of tools and resources available that align to their specific needs and will drive effective benefit utilization Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively) Emphasizes to members that Proactive CMA will be their direct contact in assisting with care coordination (i.e. between providers, collaborating within A1A, etc. Uses motivational interviewing skills that drive development and implementation of a member's plan of car As appropriate, Proactive CMAs reach out to providers for additional detail on a member's plan of care Identifies principle reason for admission, facility, and member product to correctly apply intervention assessment tools Screens 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 As needed, refers to case management: Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff Identifies triggers for referral into Aetna's Case Management, Disease Management, Mixed Services, and other Specialty Programs Utilizes ATV, ASD and other Aetna systems to build, research and enter member information, as needed Coordinates and arranges for 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 Performs non-medical research pertinent to the establishment, maintenance and closure of open cases Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems Adheres to Compliance with PM Policies and Regulatory Standards Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements Protects confidentiality of member information and adheres to company policies regarding confidentiality. May assist in the research and resolution of claims payment issues Supports the administration of the 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) 1 standards where applicable, while adhering to company policy and proceduresCOVID 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 QualificationsPlease see aboveEducationHigh School Diploma or GEDCollege degree preferredBusiness 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.
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