Analyst, Case Management

CVS Health•Decatur, IL

5d•Onsite

About The Position

This field-based Analyst, Case Management position is part of Aetna’s Long Term Services & Supports (LTSS) team and serves waiver members in the Macon County area of Illinois. The role manages a full caseload and requires in-person quarterly member visits, with travel expected 50–75% of the time. The position helps meet contractual requirements by facilitating appropriate healthcare outcomes for waiver and LTSS members through care coordination, support, and education using care management tools and resources. The analyst evaluates referred members’ needs and eligibility using care management tools and information and data review. They recommend approaches to resolve cases or meet member needs by considering benefit plans and available internal aid and external programs and services. The role identifies high-risk factors and service needs that may affect outcomes and care planning, coordinates and monitors assigned care plan activities, and refers members to clinical case management or crisis intervention when appropriate. Using a holistic approach, the analyst works with case managers, supervisors, Medical Directors, and other health programs to address barriers to care goals. They present cases for multidisciplinary review, identify and escalate quality-of-care issues, negotiate for appropriate services, and use influencing and motivational interviewing skills to encourage member engagement and healthy behavior changes. The role also coaches and supports members so they can make informed, independent healthcare and lifestyle choices and participate knowledgeably in healthcare decisions with their providers. Care monitoring, evaluation, and documentation must comply with regulatory and accreditation guidelines and company policies and procedures.

Requirements

Must reside in the Macon County area of Illinois.
Valid Illinois driver’s license.
Willingness and ability to travel up to 75% of the time for face-to-face member visits.
Reliable transportation; eligible for mileage reimbursement according to company policy.
At least two years of case management experience.
Experience with Microsoft Office and electronic health records.
A bachelor’s degree in a human-services field, or a master’s degree for a non-licensed individual, in a human-services field. Examples include sociology, special education, and rehabilitation counseling.

Nice To Haves

Case management and discharge planning experience.
Managed care experience.
Microsoft Office experience.

Responsibilities

Manage a full caseload of waiver members and conduct in-person quarterly visits.
Facilitate appropriate healthcare outcomes for waiver and LTSS members through care coordination, support, and education.
Evaluate referred members’ needs and eligibility using care management tools and information and data review.
Recommend case-resolution approaches and ways to meet member needs based on benefit plans and available internal and external programs and services.
Identify high-risk factors and service needs that may affect member outcomes and care planning, and refer to clinical case management or crisis intervention when appropriate.
Coordinate assigned care plan activities and monitor care plan progress.
Consult with case managers, supervisors, Medical Directors, and other health programs to address barriers to care goals.
Present cases at case conferences for multidisciplinary review.
Identify and escalate quality-of-care issues through established channels.
Negotiate to secure appropriate options and services for members’ benefit and healthcare needs.
Use influencing and motivational interviewing skills to promote member engagement and healthy lifestyle or behavior changes.
Provide coaching, information, and support to empower members to make independent medical and healthy lifestyle choices.
Help members participate knowledgeably with providers in healthcare decisions.
Monitor, evaluate, and document care in compliance with regulatory and accreditation guidelines and company policies and procedures.