Clinical Case Manager, Behavioral Health

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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:

Utilizes 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.

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.

• Ability to take and manage crisis calls.

Required Qualifications:

• Unencumbered Independent Behavioral Health clinical license in the state where they reside and work:

Licensed Mental Health Counselor (LMHC)

Licensed Clinical Social Worker (LCSW)

Licensed Independent Social Worker (LISW)

Licensed Marital and Family Therapist (LMFT)

Licensed Master Social Worker (LMSW)