Care Plan Reviewer - Clinical Case Manager Behavioral Health

CVS Health•Work At Home-Ohio, OH

23h•$60,522 - $129,615

About The Position

The Care Plan Reviewer (Clinical Case Manager BH) uses advanced clinical judgment and critical thinking to facilitate appropriate physical and behavioral healthcare for members. The role includes assessing needs and planning care, coordinating and collaborating directly with providers, and coordinating psychosocial wraparound services to promote effective use of resources and optimal, cost-effective outcomes. The reviewer is expected to be clinically and culturally competent and responsive, with training and experience managing complex community cases across child-serving systems. The position conducts comprehensive assessments of referred members’ needs and eligibility using clinical tools and available information, evaluates benefits and programs, and determines approaches to resolving cases and meeting needs. It applies clinical judgment to reduce risk factors and address complex clinical indicators, performs crisis intervention and follow-up, and refers members to appropriate providers for assessment and treatment as indicated. The reviewer applies relevant criteria, clinical guidelines, case management plans, policies, procedures, and regulatory standards when assessing benefits and needs. The role involves consulting with supervisors, Medical Directors, and other programs; presenting cases for multidisciplinary review; identifying and escalating quality-of-care issues; and using influencing and motivational interviewing skills to support member engagement and healthy behavior changes. The reviewer analyzes utilization, self-reported, and clinical data; coaches and supports members in making informed healthcare decisions; and develops and monitors plans of care with members and their care teams in compliance with regulatory, accreditation, and company requirements. This is a full-time position with standard business hours of Monday through Friday, 8 a.m. to 5 p.m. The role requires residence in Ohio, Kentucky, West Virginia, or Louisiana and up to 10% travel for occasional regional trainings and meetings in Ohio, including expected quarterly yearly meetings/trainings at the Columbus office.

Requirements

Must reside in Ohio, Kentucky, West Virginia, or Louisiana.
Active behavioral health license in Ohio, such as LMFT, LSW, LPC, or LISW. Colleagues residing outside Ohio must be in the process of obtaining the required licensure upon hire and are expected to secure it within 60 days of their hire date.
At least 3 years of direct clinical practice experience after earning a master’s degree, such as in a hospital, ambulatory care, or outpatient clinic/facility setting.
At least 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 families or caregivers.
At least 2 years of experience in one or more of these areas: family systems, community systems and resources, case management, child and family counseling or therapy, child protection, or child development.
Willingness and ability to travel up to 10% for occasional regional trainings and meetings in Ohio; travel to the Columbus, Ohio office for quarterly yearly meetings/trainings is also expected.
Willingness to work standard business hours, Monday through Friday, 8 a.m. to 5 p.m.
At least 1 year of experience with personal computers, keyboarding, multi-system navigation, and MS Office Suite applications.
Master’s degree in Counseling, Social Work, or Marriage and Family Therapy.

Nice To Haves

Independent clinical license preferred, such as LPCC, IMFT, or LISW.
Managed care or utilization review experience.
Case management and discharge planning experience.

Responsibilities

Conduct comprehensive assessments of referred members’ needs and eligibility using clinical tools and information or data review.
Evaluate member benefit plans and available internal and external programs and services to determine case-resolution approaches and meet member needs.
Apply clinical judgment to reduce risk factors and address complex clinical indicators affecting care planning and resolution.
Perform crisis intervention for members experiencing behavioral health or medical crises, refer them to appropriate clinical providers when indicated, and provide crisis follow-up.
Apply or interpret relevant criteria, clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards when assessing benefits and member needs.
Consult with supervisors, Medical Directors, and other programs to overcome barriers; present cases at case conferences to obtain multidisciplinary perspectives.
Identify and escalate quality-of-care issues through established channels.
Communicate with medical and behavioral health professionals to influence appropriate member care.
Use influencing and motivational interviewing skills to promote member engagement and lifestyle or behavior changes.
Provide coaching, information, and support to empower members to make independent medical and healthy-lifestyle choices and participate knowledgeably in healthcare decisions.
Analyze utilization, self-report, and clinical data to identify comprehensive member needs.
Develop and monitor plans of care in collaboration with members and their care teams.
Use case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.