Position SummaryDevelop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Position Summary/MissionUtilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.
Fundamental Components & Physical Requirements (Include but are not limited to)Assessment of Members- 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.- 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.
- 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. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Enhancement of Medical Appropriateness and Quality of Care- 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.
- 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.
- 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.
Monitoring, Evaluation and Documentation of Care- 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.
Required Qualifications- Candidate must reside in Illinois
- Candidate must possess reliable transportation and be willing and able to travel up to 25% of the time in and around candidates home locations (Mileage is reimbursed per our company expense reimbursement policy)
- Candidate must have active and unrestricted Licensed Clinical Social Worker (LCSW)/ Licensed Clinical Professional Counselor (LCPC) in Illinois
- 3-5 years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
- 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
Preferred Qualifications- Case management and discharge planning experience
- Managed care/utilization review experience
- Crisis intervention skills
Education- Master's Degree in Behavioral/Mental Health or related field (REQUIRED)
License- Active and unrestricted Licensed Clinical Social Worker (LCSW)/ Licensed Clinical Professional Counselor (LCPC) in Illinois
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.
Technical and Logistical 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
Anticipated Weekly Hours40
Time TypeFull time
Pay RangeThe typical pay range for this role is:
$66,575.00 - $142,576.00
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.
Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 09/30/2026
