Support comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of care plans to promote effective utilization of healthcare services. Promotes/supports quality effectiveness of Healthcare Services.
- Responsible for initial review and triage of Care Team tasks.
- 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.
- Monitors non-targeted cases for entry of appropriate discharge date and disposition.
- 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 eTUMS and other Aetna systems to build, research and enter member information, as needed.
- Support the Development and Implementation of Care Plans.
- 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 Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g.,health care providers, and health care team members respectively)
- 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 the 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) standards where applicable, while adhering to company policy and procedures.
- 2-4 years experience as a medical assistant, office assistant.
- High School Diploma or G.E.D.
Additional Job Information
Effective communication, telephonic and organization skills.Familiarity with basic medical terminology and concepts used in care management.Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.Ability to effectively participate in a multi-disciplinary team including internal and external participants.
High School diploma, G.E.D. or equivalent experience
Percent of Travel Required
10 - 25%
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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