Analyst, Case Management - Field

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Utilizes critical thinking and judgment to collaborate and inform the case management process, to facilitate appropriate healthcare outcomes for members by providing care coordination, support, and education for members through the use of care management tools and resources.

Schedule is Monday-Friday standard business hours. No nights, no weekends, and no holidays.

Evaluation of Members: -Through the use of care management tools and information/data review, conducts comprehensive evaluation of referred member's needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.

• Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. - Coordinates and implements assigned care plan activities and monitors care plan progress.

Enhancement of Medical Appropriateness and Quality of Care:

• Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review to achieve optimal outcomes.
• Identifies and escalates quality of care issues through established channels.

-Utilizes negotiation skills to secure appropriate options and services necessary to meet the member's benefits and/or healthcare needs.

• Utilizes influencing/ motivational interviewing skills to ensure maximum member engagement and promote 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. -Helps member actively and knowledgably participate with their provider in healthcare decision-making.

Monitoring, Evaluation and Documentation of Care:

• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

-2 years' experience in behavioral health, social services, or appropriate related field equivalent to program focus -West Virginia resident residing in one of the following counties: Braxton, Calhoun, Clay, Fayette, Gilmer, Kanawha, Nicholas, Roane, Webster-Regional -Must possess reliable transportation and be willing and able to travel in the assigned region 50% or more of the time. Mileage is reimbursed per our company expense reimbursement policy.

• 2+ years of experience with personal computer, keyboard, mouse, multi-system navigation; and MS Office Suite applications (Outlook, Word, Excel, SharePoint, Teams)

• Medicaid experience.
• Waiver experience
• Foster care experience
• Crisis intervention skills
• Managed care/utilization review experience
• Case management and discharge planning experience
• Familiarity with QuickBase

Bachelor's degree or non-licensed master level clinician required, with either degree being in behavioral health or human services preferred (psychology, social work, marriage and family therapy, counseling).

Work from Home Requirements:

• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum

download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.

• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and

HIPAA guidelines, and allowing for uninterrupted work during work hours.

• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture

(desk or standing desk, as this position would require you to be at your desk for extended periods of time).

• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to

streamline tasks and improve efficiency.

• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google

Workspace).

• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong

passwords, and recognize suspicious emails or links.

• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving

internet connection issues, and contacting IT for unresolved technical issues.

• Future Growth: Openness to learning new skills in the future as the workplace environment evolves