Position Summary

The Care Plan Reviewer (Clinical Case Manager BH) 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.

Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems.

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.

Required Qualifications

• Must be Ohio Resident.
• Active Behavioral Health license in the state Ohio (ex: LMFT, LSW, LPC, LISW).

• 3+ years of direct clinical practice experience post-Master's degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility.

• 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers.
• 2+ years of experience in one or more of the following areas of expertise: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development.
• Willing and able to travel up to 10% for occasional regional trainings/meetings in the state of OH as need basis. This includes travel to Columbus, OH office for quarterly yearly meetings/trainings is also expected.
• Willing to work standard business hours: Monday - Friday, 8am - 5pm.
• 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, and MS Office Suite applications.

Preferred Qualifications·

• Independent clinical license preferred: LPCC, IMFT, or LISW
• Managed care/utilization review experience
• Case management and discharge planning experience

Education

• Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.