Care Management Associate

CVS Health•Work At Home-Texas, TX

3d•$19 - $35

About The Position

The Care Management Associate (CMA) supports comprehensive coordination of medical services, including intake and outgoing calls. The role works closely with case management and utilization management teams to review eligibility and benefits, open pre-certification cases, and either approve cases or send them to nursing staff for review. The CMA evaluates patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals, and coordinate services under the benefit plan. The role communicates service delivery based on nurse or medical director outcomes, conducts non-medical research related to open cases, and supports team members by handling provider and member calls, reviewing electronic transmissions, and making referrals as appropriate. The CMA maintains complete and accurate documentation that meets risk management, regulatory, and accreditation requirements, and helps coordinate communication among providers and health care team members. The role also assists with obtaining discharge dates and referring cases to the clinical team for follow-up as needed. The position may require independent work and sound judgment while following department guidelines, policies, and procedures. The associate is expected to respond flexibly and promptly in a changing environment while meeting quality and quantity performance standards. The schedule is set, with shifts based on Central Time; the phone queue is open from 7 a.m. to 6 p.m. Central Time, and the preferred timeslot is 9:30 a.m. to 6 p.m. Central Time.

Requirements

At least 2 years of experience as a medical assistant, office assistant, or in a related role.
At least 6 months of call center experience.
High school diploma or equivalent GED.

Nice To Haves

Effective communication, telephonic, and organizational skills.
Familiarity with basic medical terminology and concepts used in care management.
Strong customer service skills, including attention to customers, sensitivity to issues, proactive identification and resolution of issues, and promoting positive member outcomes.
Computer literacy and ability to navigate internal and external computer systems, including Excel and Microsoft Word.

Responsibilities

Coordinate medical services through intake and outgoing calls, working with case management and utilization management teams.
Review eligibility and benefits, open pre-certification cases, and approve them or send them to nursing staff for review.
Evaluate patients using targeted intervention business rules and processes to identify needed medical services.
Make appropriate referrals to medical services staff and coordinate services required by the benefit plan.
Communicate health care service delivery based on outcomes or reviews noted by a nurse or medical director.
Conduct non-medical research related to establishing, maintaining, and closing open cases.
Answer telephone calls from providers and members, take accurate messages, review electronic transmissions, and make referrals as appropriate.
Use internal tools to determine the steps needed for proper review based on clinical requirements and plan guidelines.
Maintain accurate and complete documentation that meets risk management, regulatory, and accreditation requirements.
Communicate internally and externally with health care providers and health care team members to support effective medical management services.
Help obtain discharge dates and refer cases to the clinical team for additional follow-up when needed.
Work independently on occasion, applying judgment and critical thinking while following department guidelines, policies, and procedures.
Adapt to a rapidly changing environment while meeting quality and quantity performance standards.