We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (D-SNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand D-SNP to change lives in new markets across the country. The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by: - Complete post-discharge questionnaire, which may be market specific. - Providing comprehensive discharge planning - Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. - Benefit education - Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) - Evaluation of health and social indicators - Identifies and engages barriers to achieving optimal member health. - Uses discretion to apply strategies to reduce member risk. - Presents cases at case conferences for multidisciplinary focus to benefit overall member management. - Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage. - Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up. - Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel. - Updates the Care Plan for any change in condition or behavioral health status. Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality. What you will do - Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. - Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. - Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. - Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions Required Qualifications - 2+ years’ work experience as a Licensed Practical Nurse (LPN) - Candidate must be a Licensed Practical Nurse (LPN) with active and unrestricted status - Discharge planning experience - Advanced proficiency in Microsoft Word, Excel, and Outlook - Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care - Effective verbal and written communication skills - Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses Preferred Qualifications - Bilingual Education - High School Diploma OR Equivalent Experience (REQUIRED) - Associate's Degree (PREFERRED) - Bachelor's Degree (PREFERRED) License - Active and unrestricted Licensed Practical Nurse (LPN) Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $21.10 - $43.78 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: 04/13/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

• Reviews cases for medical necessity guidelines • Discusses determinations with physicians when available • Provides clinical rationale for appeals • Ensures documentation of communications is accurate and timely • Assists Initial Clinical Reviewers as needed

• Reviews cases in which clinical determinations cannot be made • Discusses determinations with physicians or ordering providers • Provides clinical rationale for standard and expedited appeals • Participates in on-going inter-rater reliability training and testing

• Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer. • Discusses determinations with requesting physicians or ordering providers. • Provides clinical rationale for standard and expedited appeals. • Provides assistance and acts as a resource to Initial Clinical Reviewers as needed. • Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process. • Ensures documentation of all communications with medical office staff and/or physician/provider is recorded.