4004 Aetna Medicaid Administrators

Support provider practices to improve quality and cost of care through performance analysis, education, quality assurance, and collaboration with internal teams. | 4 years healthcare quality improvement experience, knowledge of healthcare regulations and clinical operations, strong analytical skills, training delivery experience, proficiency with data tools, and remote work capability. | At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary The Quality Practice Advisor plays a critical role in supporting the highest standards of practice performance and quality within our organization's network of healthcare providers. The primary focus is to identify areas for quality improvement, partner with provider practices to implement quality strategies that improve quality and cost of care, member, and clinician experience, and drive positive outcomes in the delivery of patient care. Additional responsibilities to include but not limited to the following: - Provider Engagement: Establish and maintain engagement with small/medium provider groups that have a membership of less than 1,000. - Performance Analysis: Conduct comprehensive analysis of provider performance metrics as well as clinical operations for VBC readiness and risk assessment. This includes clinical quality indicators, patient and provider satisfaction ratings and operational efficiency measures. Identify areas of improvement and develop data-driven strategies to improve provider performance and financial rewards. - Provider Education and Practice Transformation: Collaborate with cross-functional teams to assess practice operations against industry best practices in primary care. Design and deliver training programs, workshops, and educational materials for primary care and specialty providers and their staff in key operational domains to achieve improved health outcomes. Facilitate sessions on clinic operations, quality standards, regulatory compliance, member experience and patient-centered care to enhance provider skills and knowledge. - Performance Improvement Initiatives: Lead initiatives aimed at improving provider performance. Develop and implement performance improvement plans, monitor progress, and evaluate the effectiveness of interventions in collaboration with practice partners. - Quality Assurance: Conduct regular audits, reviews, and assessments of provider practices, documentation, and compliance. Provide feedback and recommendations for improvement. - Stakeholder Collaboration: Collaborate closely with internal teams, including clinical and operational leadership, value-based care, quality management teams and provider relations teams to align provider performance objectives with organizational goals. Foster effective working relationships with providers, offering guidance, feedback, and support to facilitate their success. - Data Management and Reporting: Utilize data management systems and analytics tools to collect, analyze, and report provider performance data. Prepare comprehensive reports, dashboards, and presentations for senior leadership, highlighting key performance indicators, trends, and improvement opportunities. - Industry Knowledge and Research: Stay abreast of industry trends, best practices, and regulatory changes related to provider performance and healthcare quality. Support population health and health equity initiatives to improve care gap closure rates and health outcomes. Conduct research and benchmarking activities to identify innovative approaches and opportunities for improvement. Required Qualifications - 4 years of experience in healthcare quality improvement or a related role. In-depth knowledge of healthcare regulations, clinical operations, quality standards, and performance metrics. - Strong analytical and problem-solving skills, with the ability to interpret complex data sets and identify improvement opportunities. - Proven experience in designing and delivering training programs or educational initiatives. - Proficiency in data management and analysis tools, such as Excel or data visualization software. - Familiarity with electronic health record systems and healthcare information technology. - Position is remote – secure home network required and familiar with Microsoft Office products and VPN. Preferred Qualifications - Excellent communication, presentation, and interpersonal skills to collaborate with and effectively influence provider groups and executives, team members, and stakeholders at all levels. - Detail-oriented, organized, and able to manage multiple projects simultaneously. Ability to work independently, demonstrate initiative, and drive results in a fast-paced environment. Education Bachelor's Degree or equivalent work experience in healthcare administration, public health, or a related field. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $46,988.00 - $102,000.00 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 09/26/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.

Conduct comprehensive member assessments, develop and implement care plans, coordinate with providers and care teams, and document care activities while performing home visits. | Active unrestricted RN license in Texas, 2+ years clinical experience, ability to travel up to 50%, and residence in specified Texas counties. | At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary This is a work from home flexible position with expected travel up to 50% that will require home visits. Schedule is Monday-Friday, standard business hours, 8:00am-5:00pm CST. Key Functions Develop, implement, support, and promote health service strategies, tactics, policies, and programs that drive the delivery of quality healthcare to our members. Health service strategies, policies, and programs are comprised of utilization management, quality management, network management, clinical coverage, and policies.` The position requires advanced clinical judgment and critical thinking skills to facilitate appropriate physical, behavioral health, psychosocial wrap around services. The care manager will be responsible for, care planning, direct provider collaboration, and effective utilization of available resources in a cost-effective manner. Strong assessment, writing and communication skills are required. The Case Manager is responsible for conducting face to face visits in the members home utilizing comprehensive assessment tools for members enrolled in Long-Term Services and Support programs. The case manager is responsible for coordinating and collaborating care with the member/authorized representative, PCP, and any other care team participants. The case manager schedules and attends interdisciplinary meetings and advocates on the members behalf to ensure proper and safe discharge with appropriate services in place. The case manager works with the member and care team to develop a care plan and authorizes services in a cost-effective manner within the LTSS benefit. The care manager is responsible for documenting accurately and timely in the member’s electronic health record. This position requires the case manager to use critical thinking skills and the ability to problem solve. Assessment of Members: Through the use of care management tools and information/data review, the Case Manager 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 members outcome and care planning components with appropriate referrals. Coordinates and implements assigned care plan activities and monitors care plan progress. Enhancement of Medical Appropriateness and Quality of Care: Uses a holistic approach to overcome barriers to meet goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order 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 knowledgeably participate with their provider in healthcare decision-making. Required Qualifications Active and unrestricted RN license in the state of TX 2+ years of clinical experience Must reside in Tarrant County or Dallas County of TX Willing and able to travel up to 50% of their time to meet members face to face Tarrant County, Dallas County, or surrounding counties Reliable transportation required; mileage is reimbursed as per company policy Preferred Qualifications Case Management and/or home health care experience Managed care organization (MCO) experience Pediatric experience Education Minimum of an Associate degree in Nursing required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $60,522.00 - $129,615.00 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 09/26/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.

Supervise customer service employees, motivate and coach staff, monitor performance metrics, ensure regulatory compliance, and foster team cohesion to improve member/provider satisfaction and retention. | Demonstrated leadership abilities, experience with inbound call center operations, preferably 2 years leading customer service teams, and a Bachelor's degree or equivalent experience. | At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary - Must Reside on the Eastern Seaboard Responsible for increasing member and provider satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes. Responsible for the overall supervision of Customer Service employees. Accountable for member/provider satisfaction, retention, and growth by efficiently delivering competitive services to members/providers. Additional responsibilities to include but not limited to the following: - Develops, motivates, evaluates and coaches staff on work procedures, proper call handling and teamwork delivering excellent customer service. Is visible and available to staff to answer questions, monitor calls and give ongoing feedback. - Utilizes available incentive programs to reward, recognize and celebrate team and individual successes. - Assesses individual and team performance on a regular basis and provide candid and timely feedback regarding developmental and training needs; includes completion of monthly and annual scorecards. - Monitors all performance measures such as daily stats and schedule adherence; allocates resources to meet volume and performance demands. - Remove barriers to job performance and ensures regulatory compliance. - Attracts, selects, and retains high caliber, diverse talent able to successfully achieve or exceed business goals. Builds a cohesive team that works well together. - Acts as liaison between staff and other areas, including management, all segments, provider teams, etc., communicating workflow results, ideas, and solutions. - Proactively analyzes constituent data, identifies trends and issues. Recognizes and acts on the needs to improve the development and delivery of products and services. Clearly identifies what must be accomplished for successful completion of business objectives. - Effectively applies and enforces Aetna HR policies and practices, i.e., FML/EML, Attendance, Code of Conduct, Disciplinary Guidelines. Required Qualifications Demonstrated leadership abilities. Experience with inbound call center operations. Preferred Qualifications - 2 years leading member/customer service team. - Experience in a Medicaid and/or Medicare setting. Education - Bachelor's Degree or equivalent work experience Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $43,888.00 - $93,574.00 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 09/19/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.