Behavioral Health Nurse - Managed Care

DOCTORS HEALTHCARE PLANS, INC.•Coral Gables, FL

2d•Onsite

About The Position

The Behavioral Health Nurse – Managed Care is responsible for coordinating, monitoring, and delivering behavioral health services within a managed care environment. This role involves working closely with patients, providers, and interdisciplinary teams to assess behavioral health needs, develop individualized care plans, and ensure cost-effective, quality care in accordance with regulatory guidelines and organizational policies.

Requirements

Current and unrestricted RM license in Florida
Minimum 2-3 years of clinical nursing experience, including behavioral/mental health
Experience in a managed care, case management, or utilization review setting
Strong understanding of behavioral health diagnoses, treatments, and psychotropic medications
Knowledge of Medicaid, Medicare, and/or commercial insurance policies
Demonstrates commitment to the Partners-in-Caring process and the behavioral expectations in all interactions and in performing all job duties.
Able to maintain confidentiality of sensitive information.
Excellent communication and interpersonal skills
Strong critical thinking and clinical judgment
Ability to manage multiple cases and prioritize tasks
Proficiency with EHRs, care management software, and Microsoft Office Suite
Compassionate, patient-centered approach
Understanding of cultural competence and trauma-informed care

Nice To Haves

Bachelor’s or master’s degree in nursing (BSN/MSN)
Certified Case Manager (CCM) or similar certification
Fluent in Spanish preferred.

Responsibilities

Conduct comprehensive assessments of members’ behavioral and mental health status, including psychosocial and medical needs.
Develop and implement individualized care plans, with an emphasis on behavioral health and comorbid conditions.
Monitor treatment progress, adherence, and outcomes, coordinating adjustments with providers as necessary.
Collaborate with psychiatrists, primary care providers, therapists, social workers, and community resources.
Authorize services and coordinate referrals based on clinical guidelines and insurance coverage.
Provide telephonic and/or in-person case management and member education regarding conditions, medications, and treatment options.
Ensure services are cost-effective and meet quality standards, consistent with managed care requirements and clinical best practices.
Maintain accurate and timely documentation in electronic health records and care management platforms.
Identify and intervene in high-risk cases to reduce emergency department visits and hospital admissions.
Participate in interdisciplinary case rounds, quality improvement initiatives, and utilization review processes.
Support members during transitions of care, including discharge planning and follow-up coordination.
Stay informed on behavioral health regulations, evidence-based practices, and managed care policies.
Presents case for patients not meeting criteria for medical necessity for the requested level of care/patient status to the Medical Director.
Proactively identifies and resolves delays and obstacles for safe discharge. Seeks consultation from appropriate disciplines/departments to expedite care and facilitate safe discharge.
Collaborates with family, health care team, payors, and providers to achieve appropriate resource management to implement safe discharge plan of care established by health care team and family.
Assists in identifying and reporting variances in utilization of resources, avoidable days/denials. Works in collaboration with Appeals Management/Medical Director in the appeals process.
Responsible for the appropriate use of software and applications and enters case management information accurately and in a timely manner.
Adheres to Medicare and Medicaid regulatory guidelines as it pertains to patient admission/safe discharge.
Participates in utilization management initiatives/opportunities for improvement through departmental committee assignments.