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LTSS Care Management Auditor RN or LCSW

at CVS Health

Posted: 11/9/2020
Job Reference #: 74512BR
Keywords: compliance

Job Description

Job Description
Under the direction of Manager of Program Integrity, conduct assigned audits of CM processes and notes to assure maximum compliance with the CM Standard Operating Model. The incumbent must demonstrate strong clinical judgment, knowledge of care management processes and systems. The Auditor must understand/be familiar with the regulatory and accreditation requirements for Medicaid managed care, and waste, fraud and abuse.

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

Fundamental Components
  • Consistently reinforces the Aetna Medicaid clinical philosophy and CM Standard Operating Model.
  • Applies audit review criteria to assess full compliance with CM programs, policies and procedures.
  • Works closely with clinical department leadership to ensure consistency and accuracy care management processes and alignment with any state-specific requirements.
  • Assesses CM functions for compliance with NCQA CM standards
* Completes assigned audit deliverables in a timely, efficient and accurate manner, meeting all identified deadlines.
* Enters and maintains all required data elements in designated audit tool, as directed.
  • Identifies opportunities to implement best practice approaches and innovations to improve outcomes and enhance organizational efficiency.
* Meets all performance expectations and organizational goals.
  • Mindfully sustains a high level of accountability.
  • Consistently demonstrates the ability to serve as a model change agent and inform change efforts.
  • Is accountable for maintaining compliance with policies and procedures at the employee level.
Participates in the evaluation and interpretation of data to identify areas with opportunity for improvement and interventions to improve care management review outcomes.

Background Experience
  • Minimum of 5 years of clinical nursing or clinical behavioral health required
  • 1+ year of managed care experience required
  • 3+ years of care management experience
  • Functional knowledge of managed care concepts, preferably including Medicaid and/or Medicare.
  • Knowledge of Medicaid managed care management preferred
  • Up-to-date knowledge of NCQA CM standards desirable
  • High level of efficiency, accuracy, integrity and attention to detail
  • Ability to identify variances from standard operating procedures/policies
  • Ability to work to deadlines and assume accountability for timely, accurate deliverables
  • Excellent interpersonal communication skills, verbal and written
  • Ability to self-motivate and thrive in a team setting
  • Utilize and adhere to RN Audit procedures and processes
  • Ability to optimize available resources using excellent judgment, and an attitude that fosters teamwork and supports organizational goals
  • Adaptability in a fast-paced environment
  • Creative problem-solving skills and awareness of continuous quality improvement concepts
  • Proficiency with Microsoft Office applications (Outlook, Word, Excel, PowerPoint)
LICENSE required ACTIVE AND UNRESTRICTED one of the following:

Additional Job Information
Typical office working environment with productivity and quality expectationsWork requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.Ability to multitask, prioritize and effectively adapt to a fast paced changing environmentPosition requires proficiency with computer skills which includes navigating multiple systems and keyboardingEffective communication skills, both verbal and written.

Bachelor's degree or equivalent experience

Percent of Travel Required
0 - 10%

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.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!