BH Clinician II-1 (Clinical Advocacy Program)

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

This position is responsible for performing behavioral health duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new BH Clinicians and other staff as needed during the performance of their daily job duties.

Responsibilities:

• Assesses patient's behavioral health clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.  Additionally, where applicable, ensure that the services provided are medically appropriate to member's needs, aligned with the benefit structure, and that they have the appropriate supports to be successful with their treatment.

• Evaluates the necessity, appropriateness and efficiency of behavioral health medical services and procedures provided, for both acute and chronic health care needs when applicable.

• Develops, coordinates and assists in implementation of plan for members and of individualized plan of care for members and identification of barriers towards Self- Management and optimal wellness.

• Demonstrates a high level of knowledge and understanding of the application of Milliman Care Guidelines (MCG) and American Association of Addiction Medicine (ASAM) criteria to medical necessity criteria.

• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and coordinates internally for negotiation of fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care, including transitional care where applicable.

• Monitors patient's behavioral health medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

• Encourages member participation and compliance in the behavioral health case/disease management program efforts.

• Documents accurately and comprehensively based on the standards of practice and current organization policies.

• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.

• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

• Serves as mentor/trainer to new BH Clinicians and other staff on an ongoing basis.

• Serves as an escalation point for cases and issues that require additional attention.

• Coordinates the implementation of clinical process improvement with the support of the team supervisor.

• Works independently on special projects in conjunction with the supervisor that support the needs of the business.

• Provides feedback and collaborates with department supervisor in evaluating areas of needed improvement within the team.

• Completes other assigned functions as requested by management.

• Works independently on complex cases.

• Recommend workflow and process improvements

• Execute UAT test cases thoroughly from end to end.

• Required to work one holiday shift per year.