Care Management Associate

This is a fully remote position, open to applicants in Arizona, +2 more states.

📋 Description

• Assess patients utilizing specific intervention business rules and processes to recognize necessary medical services.

• Make suitable referrals to medical services personnel and coordinate services in alignment with the benefit plan.

• Convey health care service delivery based on outcomes and evaluations from nurses or medical directors.

• Conduct non-medical research to establish, maintain, and conclude open cases.

• Respond to provider and member phone inquiries, accurately relay messages, and assist with electronic transmission reviews and referrals.

• Utilize internal tools to ascertain required review steps based on clinical prerequisites and plan guidelines.

• Ensure precise and comprehensive documentation that complies with risk management, regulatory, and accreditation standards.

• Facilitate internal and external communication to improve medical management services.

• Acquire discharge dates and refer cases to the clinical team for further follow-up.

• Conduct initial reviews and triage Care Team tasks.

• Determine admission reasons, facilities, and member products to implement intervention assessment tools.

• Employ Aetna systems to construct, investigate, and input member data.

• Assist in the development and execution of care plans.

• Coordinate health care delivery under the guidance of nurses or medical directors, including participating providers and services.

• Aid in the research and resolution of claims payment issues.

• Support hospital care, case management, and quality management processes in accordance with applicable laws, regulations, URAQ/NCQA, CMSA standards, and company protocols.

• Safeguard member confidentiality and comply with company policies.

• Complete tasks independently while demonstrating judgment, critical thinking, urgency, and adaptability.

⛳️ Requirements

• Must be located within an hour of New Albany, Ohio, Phoenix, Arizona, or High Point, North Carolina.

• A minimum of 2 years of experience in customer service, telemarketing, and/or sales.

• Alternatively, a minimum of 5 years of equivalent relevant experience.

• Proficient typing skills for inputting information and navigating multiple systems.

• Experience with computers, including Microsoft Word, Outlook, and Excel.

• High school diploma or equivalent GED, or 5+ years of equivalent experience.

• Capacity to work for extended periods while seated, performing telephone and computer tasks.

• Strong problem-solving and decision-making abilities.

• Experience with data entry and documentation within member records is preferred.

• Prior experience in a medical office is preferred.

• Call center experience is preferred.

• Familiarity with medical terminology is preferred.

• Excellent telephonic communication skills are preferred.

• Strong organizational abilities and the capacity to prioritize time-sensitive tasks are preferred.

• Effective verbal and written communication skills with customers and colleagues are preferred.

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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