Coordinates the socio economic needs and service of selected member populations across the continuum of illness. Performs member psychosocial assessments to create and implement care plans, and monitors and evaluates services and outcomes to maximize the health of the member through the care plan. Interviews, coordinates and plans activities and behavioral routines to meet the social and medical needs of members and their families. Manages members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. Provides support and/or intervention and assists members in understanding the implications and complexities of their current medical situation and/or overall personal care.
Reports to: Director, Product Operations- Behavioral Health
Department: Health Services
Position Location: Columbia, SC 29210
- Assesses, plans, implements, coordinates, 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 assessments of referred member's needs and benefit plan eligibility, and develops a care management treatment plan for members with high level acuity needs.
- 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 social work 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/support medical needs. Reviews benefits options, researches community resources, coordinates services, trains/creates behavioral routines and enables members to be active participants in their own healthcare.
- Provides telephone follow-up to ensure members have seen their PCP and are completing their care management treatment plan or preventive care services as defined by the PCP or guidelines.
- Coordinates community resources with emphasis on the development of natural support system. Coordinates benefits, regulations, laws and public entitlement programs.
- Assists in obtaining benefits for members through community resources when benefits are exhausted or not available.
- May manage members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. Acts as team SME in order to achieve optimal clinical and resource outcomes.
- Performs other duties as assigned.
- Required An Associate's Degree in nursing or graduation from Diploma Nursing School (if RN)
- 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 Other Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
- Preferred Other 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 Other One of the following is required:
- 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 Proficient in Microsoft Office including 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 Microsoft Excel
- Required Intermediate Other 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.