Transition of Care Service Coordinator, CVS Health

CVS Health

Location:

United States, San Antonio

Category:

Nursing

Contract Type:

Employment contract

Salary:

60522.00 - 129615.00 USD / Year

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Job Description:

The Transition of Care Service Coordinator is responsible for care coordination of members experiencing significant health changes resulting in inpatient admission. Ensures seamless transitions to subsequent care settings and provides proactive assistance to optimize outcomes and enhance members’ overall wellness.

Job Responsibility:

Responsible for telephonic and/or face to face assessing, planning, implementing, and coordinating all care management activities with members to evaluate the medical and behavioral health needs to facilitate the member’s overall wellness
Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration
Using clinical tools and information/data review, conducts comprehensive assessments of member’s needs and recommends an approach to case resolution by meeting needs in alignment with their benefit plan and available internal and external programs and services
Applies clinical judgement to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues
Complete assessments taking into account information from various sources to address conditions including co-morbid and multiple diagnosis that impact functionality and include the member’s restrictions/limitations
Ability to speak to medical and behavioral health professionals to influence appropriate member care
Use advanced clinical skills to perform crisis intervention with members experiencing a behavioral or medical crisis and refer them to the appropriate clinical providers for assessment and treatment as clinically indicated
Attends and participates in case rounds, including utilization management rounds for behavioral health and physical health to obtain multidisciplinary view to achieve optimal outcomes
Collaborates with the member, and inpatient facilities to coordinate discharge needs including ensuring post discharge needs are met
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation
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
In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals
Utilizes care management processes in compliance with regulatory and company policies and procedures
Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and throughout subsequent care continuum
Facilitates clinical hand offs during transitions of care

Requirements:

Active current unrestricted RN licensure in the state of Texas OR Licensed Social Worker in the state of Texas
Must reside in Bexar County or adjacent county
3+ years clinical practice experience, e.g. hospital setting
3+ years of discharge planning experience
2+ years’ experience managing complex medical
2+ years behavioral health conditions
Willing and able to travel 50% of their time to meet members face to face in the Bexar County area
Reliable transportation required
Mileage is reimbursed per our company expense reimbursement policy
2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications
and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)

Nice to have:

Behavioral Health Experience
Case management in an integrated model
Experience providing care to the Medicaid population
Bilingual in Spanish

What we offer:

Eligible employees may enroll in the Company’s 401(k) retirement savings plan
Employee Stock Purchase Plan
Fully-paid term life insurance plan
Short-term and long term disability benefits
Numerous well-being programs
Education assistance
Free development courses
CVS store discount
Discount programs with participating partners
Paid Time Off
Paid holidays

Additional Information:

Job Posted:

March 29, 2025

Expiration:

March 31, 2025

Employment Type:

Fulltime

Work Type:

On-site work

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