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We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Summary/Position Objectives: Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. This position requires the colleague to live within the Southern Bluegrass Region which includes counties: Fayette, Clark, Jessamine, Madison, Mercer, Boyle, Lincoln, Gerrard, Estill, Powell.
Job Responsibility:
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services
Assessment of Members: Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues
Performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services
Enhancement of Medical Appropriateness and Quality of Care: Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives
presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes
Identifies and escalates quality of care issues through established channels
Ability to speak to medical and behavioral health professionals to influence appropriate member care
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes 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
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs
Monitoring, Evaluation and Documentation of Care: In collaboration with the member and their care team, develops and monitors established plans of care to meet the member’s goals
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures
Requirements:
3-5 years of direct clinical practice experience post Master’s degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
Case management and discharge planning experience preferred
Minimum of a Master's degree in Behavioral/Mental Health or related field
Unencumbered Behavioral Health clinical license in Kentucky (LCSW, LPCC, LMFT)
Nice to have:
Crisis intervention skills
Managed care/utilization review experience
Case management and discharge planning experience
What we offer:
Affordable medical plan options
a 401(k) plan (including matching company contributions)
an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility