Fundamental Components:
o 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.
o 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.
o Using advanced clinical skills, 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, as clinically indicated.
o Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
o 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.
o 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.
o 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.
o 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.
Specific to the OHRise contract, responsibilities include but are not limited to:
a. Serve as the OhioRISE Plan’s primary points of contact for ODM-approved improvement efforts involving community-based organizations and requiring community outreach and active involvement in priority communities (e.g., juvenile detention diversion initiatives or reduction in efforts to reduce out–of-home placements);
b. Serve as the OhioRISE Plan’s dedicated contact for county or local child serving agencies. Attend or oversee OhioRISE Plan attendance at community events in priority communities (e.g., trainings; County Alcohol Drug and Mental Health Boards [ADAMH], Boards of Developmental Disability, PCSA, Family and Children First Councils, Juvenile Courts, and School District meetings; and racism dialogues);
c. Provide in-person communication with ODM or other state agency funded community-based organizations in order to bolster the presence of the OhioRISE Plan itself as a collaborative and trusted partner of the community-based organization and as a supporter of the ODM initiative;
d. Coordinate training for county or local child-serving entities regarding the roles and responsibilities of the OhioRISE Plan and the CMEs;
e. Collaborate with the CMEs to identify service and resource gaps in local communities and assist state and local child-serving agencies in addressing those gaps;
f. Collaborate with MCO’s Regional Coordinators to collectively strategize and address community concerns;
g. Coordinate the tracking and submission of process measures, as needed, related to OhioRISE Plan’s improvement efforts in communities (e.g., reductions in out-of-home placements);
h. Promote the referral of members to community-based organizations when services are provided that will promote better outcomes;
i. Respond to ODM inquiries related to OhioRISE Plan’s community engagement activities; and
j. Build alliances with family- and youth-run organizations to strengthen family and youth voice in OhioRISE Plan’s operations.
Required Qualifications
Preferred Qualifications
Education
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
We reserve the right to pay above or below the posted wage based on factors unrelated to sex, race, or...
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