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Position Summary

Help us elevate our member care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Fully Integrated Dual Eligible Plan (FIDE) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country.

The Transition of Care-Case Manager is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The TOC CM ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by:

• Complete post-discharge questionnaire, which may be market specific.

• Providing comprehensive discharge planning

• Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications.

• Benefit education

• Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)

• Evaluation of health and social indicators

• Identifies and engages barriers to achieving optimal member health.

• Uses discretion to apply strategies to reduce member risk.

• Presents cases at case conferences for multidisciplinary focus to benefit overall member management.

• Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage.

• Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up.

• Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel.

• Updates the Care Plan for any change in condition or behavioral health status.

Our TOC Case Managers are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.

Responsibilities

• Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines.

• Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions.

• Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community.

• Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.

Required Qualifications:
• Minimum 3+ years of clinical practice experience
• Must have active and unrestricted NJ RN or compact license

Preferred Qualifications:
• Certified Case Manager is preferred.
• Minimum 3+ years Care Management, Discharge Planning and/or Home Health Care Coordination experience preferred
• Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually
• Excellent analytical and problem-solving skills
• Effective communications, organizational, and interpersonal skills.
• Ability to work independently
• Effective computer skills including navigating multiple systems and keyboarding
• Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications
• Bilingual Preferred - Spanish

Education

Associate's Degree or Nursing Diploma Required
Bachelor's Degree in Nursing Preferred

Pay Range

The typical pay range for this role is:

$72,627.36 - $155,538.24

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. 
 
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: 11/01/2024

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

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work. CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through [email protected] If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.