Manages members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. Acts as provider liaison to oversee the Community Based Case Management (CBCM) Agencies who deliver and coordinate the behavioral services of the CCS contract. Monitors CCS contract compliance of the CBCM Agencies by collecting clinical data and maintaining accurate records for tracking and metric purposes.
DEPARTMENT: Health Services-Behavioral Health
REPORTS TO: Behavioral Health Medical Director
- Manages members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability.
- Acts as provider liaison to oversee the Community Based Case Management (CBCM) Agencies who deliver and coordinate the behavioral services of the CCS contract.
- Identification and tracking of all assigned members of assigned CBCM agencies.
- Audits member records for compliance of CCS contract.
- Collects clinical data and maintains accurate records for tracking and metric purposes.
- Oversees CCS contract compliance of the CBCM agencies (i.e. Behavioral Health Assessment (BHA)/Individualized Treatment Plan (ITP) received within specified timeframes, quarterly BHS reports, post hospitalization follow up, etc.).
- Maintains ongoing contact with assigned CBCM agencies.
- Participates in agency educational meetings and agency visits.
- Facilitates enrollment and eligibility changes.
- Performs other duties as assigned.
- Notifies CBCM Agency when a member is admitted for a Behavioral Health Inpatient Hospitalization.
- Reviews authorization requests for CCS program benefits.
- Serves as Officer of the Day (OOD) to address calls from customer service and internal 'Ohana staff.
- Processes Adverse Events.
- Coordinates with member's QUEST Integration Health Plan Service Coordinator for continuity of care.
- Holds Interdisciplinary Team (IDT) Meetings for complex, high-risk, high-utilizing members and participates in departmental clinical rounds.
*LI-Wellcare Candidate Education:
- 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: A license in one of the following is required:
- 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
- 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 Psychologist
- Required Licensed Clinical Marriage & Family Therapist (LCMFT)
- Required Licensed Clinical Psychologist (LCP)
- 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)