Conducts comprehensive member psychosocial assessments through root cause analysis and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs. Manages members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. Assess members to recommend activities and behavioral routines to meet the social and medical needs of members and their families. Provides support and/or intervention and assists members in understanding the implications and complexities of their current medical situation and/or overall personal care.
DEPARTMENT: Health Services
REPORTS TO: Sr. Director, Field Health Services/Field Case Management
- Assesses, plans, implements, monitors and evaluates options and services to meet complex psychosocial health needs of inpatient and outpatient members. Manages a caseload in compliance with contractual obligations and WellCare standards.
- Conducts comprehensive member assessments through root cause analysis based on referred member's needs and benefit plan eligibility, and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs.
- Manages members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. Works towards achievement of optimal clinical and resource outcomes.
- Monitors and evaluates effectiveness of care plan and modifies plan as needed. Supports member access to appropriate quality and cost effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers.
- Acts as a liaison and member advocate between the member/family, physician and facilities/agencies. Provides clinical consultation to physicians, professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations.
- Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs. Reviews benefits options, researches community resources, trains/creates behavioral routines and enables members to be active participants in their own healthcare.
- Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services.
- Assists in obtaining benefits for members through community resources when benefits are exhausted or not available.
- Performs other duties as assigned.
- Required a Master's Degree in Social Work, Psychology, Counseling, Rehabilitation, or other relevant field that provides a foundation to receive a license as required of the position
- Required 2 years of experience in behavioral health management and/or acute behavioral health care setting focusing on outpatient/inpatient utilization, case management and discharge planning
- Required 1 year of experience in current case management as a licensed professional
- Required experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
- Preferred experience in a managed care environment
Licenses and Certifications:
- Intermediate ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
- Intermediate ability to multi-task
- Intermediate demonstrated time management and priority setting skills
- Intermediate demonstrated interpersonal/verbal communication skills; communicates effectively in person and by phone
- Advanced ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
- Intermediate ability to effectively present information and respond to questions from families, members, and providers
- Intermediate knowledge of healthcare delivery
- Intermediate knowledge of community, state and federal laws and resources
- Intermediate demonstrated written communication skills
- Intermediate demonstrated customer service skills
- Intermediate ability to effectively present information and respond to questions from peers and management
- Intermediate demonstrated problem solving skills
A license in one of the following is required:
- Required a master's level independent or non-independent license is required OR an RN with a behavioral health background:
- Required Licensed Registered Nurse (RN)
- Required Licensed Clinical Social Worker (LCSW) LSW, LCSW, LMHC, LPC, LMFT, PsyD
- Required Licensed Clinical Mental Health Counselor (LCMHC)
- Required Licensed Clinical Professional Counselor (LCPC)
- Required Licensed Clinical Marriage & Family Therapist (LCMFT)
- Required Licensed Clinical Psychologist (LCP)
- Required Licensed Master Social Work (LMSW)
- Required Certified Social Worker (C-SW)
- Required Acute Care Nurse Practitioner (APRN) (ACNP-BC)
- Required intermediate Microsoft Outlook, Word and Excel
- Required intermediate Microsoft Word Knowledge of or the ability to learn company approved software such as EMMA, CRMS, Peradigm, InterQual, Sidewinder and other software in order to perform job duties
- Required Intermediate Healthcare Management Systems (Generic)