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Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

This position oversees the implementation and on-going execution of the strategic and operational business plan for the business segment's clinical operations, inbound/outbound call queue, implementation, and/or plan sponsor operations. Coordinates business segment policies and procedures in support of financial, operational, and service requirements. Implements care coordination services provided to plan populations in order to meet specific regulatory requirements and provide holistic bio-psychosocial care to members in a cost-effective manner. As a member of the Key Personnel team for Aetna Better Health of Texas, the candidate will need to travel to required meetings throughout the state.

Fundamental Components

• Leads a clinical team that supports timely Health Risk Screenings, Comprehensive Assessments, Care Plan development and Enrollee interventions in accordance with the State contracts
• Develop and manage clinical operations focused on improving clinical and financial outcomes, member engagement, member satisfaction, and use of best practices and standards.
• Serve as liaison with regulatory and accrediting agencies and other health business units.
• Formulate and implement strategies for achieving applicable department/unit metrics and provide operational direction.
• Responsible for cross-functional integration of care management, program operations with core organization-wide business functions including claims, member services, compliance, quality, utilization management, and network/provider services.
• Serve as technical, professional, and business resource (may cross multiple business functions).
• Support quality improvement projects through successful implementation.
• Develop and participate in presentations and consultations to existing and prospective stakeholders.
• Direct/provide enhancements to business processes, policies, and infrastructure to improve clinical operational efficiency (may cross multiple business functions).
• Develop, implement, and evaluate policies and procedures, which meet business needs (may cross multiple business functions).
• Implements and monitors business plan and oversees any implementations or business transitions impacting clinical operations.
• Collaborates and partners with other business areas across/within regions or segments and within other centralized corporate areas to ensure all workflow processes and interdependencies are identified and addressed on an on-going basis.
• Ability to synthesize program performance and clinical outcomes.
• Promote a clear vision aligned with company values and direction; sets specific challenging and achievable objectives and action plans; motivates others to balance customer needs and business success; challenges self and others to look to the future to create quality products, services, and solutions.
• Knowledge of the regulations, standards, and policies which relate to medical management. Ability to communicate in a highly effective manner with internal and external constituents in both written and oral format. Ability to evaluate and interpret data for the purposes of monitoring staff performance, regulatory compliance, and development of new programs and processes to meet business demands.

Required Qualifications

• Must reside in Texas.
• Texas-licensed registered nurse with current unencumbered license and experienced in the activities of Care Management.
• Nationally recognized case management certification, or ability to obtain within 90 days.
• 5+ years of clinical practice experience in physical or behavioral healthcare.
• 5+ years of management or clinical leadership.
• 3+ years of experience with personal computer, keyboard navigation, and MS Office Suite applications.
• Must possess reliable transportation and be willing and able to travel in-state up to 15% of the time. National travel intermittently. Mileage is reimbursed per our company expense reimbursement policy.

Preferred Qualifications

• Master’s degree preferred.
• Medicaid, insurance, managed care, experience.

Pay Range

The typical pay range for this role is:

$110,467.50 - $237,930.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.  This position also includes an award target in the company’s equity award program. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. 
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 12/31/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.