Clinical Case Manager Behavioral Health - Louisiana

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Business Overview:

The mission of Aetna Better Health of Louisiana (ABH-LA) is to build a healthier world through better health, better care, and lower costs. We have embraced the quintuple aim as our guiding framework that integrates population health, equity, cost reduction, patient experience, and care team wellbeing into everything we do. We are leading the change by challenging the status quo with new technologies, VPB models, innovation, and integration of behavioral and physical health; and attracting and inspiring our local team by unlocking the power of our people to transform health care.

Position Summary:

The Clinical Case Manager Behavioral Health (CM-BH) utilizes advanced clinical judgement 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. 

The Clinical Case Manager BH is a full time telework position in Louisiana.  In-state travel is required to conduct face to face visits and in-person outreach.  This position is ABH- Louisiana Children’s Specialty Foster Care program.

Schedule is Monday – Friday, 8am-5pm, standard business hours. No nights, weekends, and no holidays. A flexible work schedule may be available after 6 months of service and with demonstrated performance and attendance.

Fundamental Components:

Assessment of Members:

• Using 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 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 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 the