Care Management Associate

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Review, intake, screen, and triage Utilization Management and Care Management tasks in accordance with established workflows, guidelines, and business rules.

• Collect, research, and verify information related to members, providers, facilities, admissions, authorizations, and other case-related data.

• Prepare cases and distribute work to nurses, medical directors, and other clinical partners.

• Conduct outbound communication with providers and facilities to gather, clarify, or confirm information.

• Monitor tasks for missing information, discharge details, documentation requirements, or conditions needing follow-up or escalation.

• Identify triggers for referrals or transitions to Care Management, Disease Management, Transition of Care, and other clinical programs.

• Document calls, actions, research, outcomes, and follow-up activities in the designated systems.

• Navigate various systems, work queues, provider portals, and technology tools while ensuring data accuracy.

• Perform non-clinical research to establish, maintain, process, and close cases effectively.

• Manage assigned tasks within turnaround times and escalate any obstacles or aging work.

• Meet productivity and quality standards while enhancing positive experiences for members, providers, and internal stakeholders.

• Safeguard PHI/PII and adhere to HIPAA, privacy, security, regulatory, accreditation, and company policies.

⛳️ Requirements

• A minimum of 2 years of experience in health insurance, healthcare operations, provider services, medical office operations, Utilization Management/Care Management support, prior authorization, or a similar healthcare setting.

• High school diploma or GED required.

• Safeguard PHI/PII and comply with HIPAA, privacy, security, regulatory, accreditation, and company policies.

• Proficient in working across multiple systems, applications, work queues, provider portals, and technology tools.

• Ability to meet turnaround time, productivity, quality, and documentation expectations.

• Strong attention to detail and effective time management skills.

• Preferred: Previous experience in supporting Utilization Management, prior authorization/precertification, concurrent review, discharge verification, post-acute care, or Care Management.

• Preferred: Experience with Medicare/Medicare Advantage and/or Commercial health plans.

• Preferred: Familiarity with MedCompass or another utilization or case management platform.

• Preferred: Experience utilizing healthcare provider portals and research tools.

• Preferred: Prior experience in a remote healthcare operations environment.

• Preferred: Knowledge of productivity, quality-audit, and turnaround-time performance metrics.

• Preferred: Medical billing or coding knowledge, including ICD-10, CPT, and/or HCPCS.

• Preferred: Understanding of NCQA, URAC, HIPAA, and other healthcare regulatory or accreditation standards.

• Preferred: Associate degree or higher in healthcare, business, or a related field.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program in addition to base pay.