Clinical Care Manager II (Union) - Michigan Licensed

Elevance Health•Dearborn, MI

2d•Remote

About The Position

The Clinical Care Manager II provides assessments, referrals, and counseling. Conducts telephone assessments, collecting sufficient clinical information to make appropriate referral and certification decision for emergency/urgent referrals that require alternate levels of care. Makes appropriate certification decisions. Collaborates with providers to determine alternate levels of care and to facilitate transfers to network facilities and providers whenever possible. Facilitates coordination of care with other managers to assure continuity of care. Evaluates clinical appropriateness of treatment using professional knowledge within Carelon Behavioral Health Options clinical and work site guidelines and renders certification decisions or seeks consultations for non-certification decisions. Will facilitate all tracking for necessary quality indicators to meet these necessary accrediting bodies (NCQA, URAC). Directs members to an appropriate therapist or EAP provider and reviews care on a regular basis to determine whether treatment meets Carelon Behavioral Health Options criteria for medical necessity. Refers cases to an MD or Clinical Management staff if unable to determine that medical necessity criteria have been met. Establish and deliver knowledge about care resources and levels of care availability. Special projects and all other duties as assigned.

Requirements

Master’s degree in social work, psychology, counseling or a Bachelor’s level RN.
Current, valid and unrestricted license in the State of Michigan in a mental health field (RN, Ph.D., LCSW/ACSW, LLP, MHC, LPC, etc.).
A minimum of 3 years’ experience in psychiatric or substance abuse treatment.
Experience as a CEAP or EAP internal/external consultant to a work site area required (for the integrated unit only), or A minimum of 2 years’ experience, prior to licensure with Carelon Behavioral Health Options Clinical Operations Unit functioning as a Clinical Support Specialist with required licensure activities supervised by the Clinical Manager or Clinical Director.

Nice To Haves

Experience in settings that include inpatient, partial, and/or outpatient care preferred.

Responsibilities

Coordinate with other Care Managers to assure that patient comprehensive treatment needs are met.
Ensure continuity of patient care through contact with providers.
Monitor use of, and regulate release of benefits based on medical necessity.
Handle provider calls and assess request for approval of release of benefits.
Review and monitor cases.
Provide follow-up contact and correspondence.
Verify benefit coverage to determine that it is active and available in relation to contract terms and annual limits.
Complete telephone assessments and referral; gathers demographic and clinical information to connect patient with appropriate provider, including outpatient treatment as necessary; and for emergency, urgent, routine and EAP referrals.
Provide appropriate referrals for treatment based in assessment of information gathered during telephone contacts and or on-site with providers.
Refer cases that do not meet criteria and need non-cert., to Peer Advisors.
Manage release of MHSA benefit provided by carrier for designated group.
Ask questions and listen to member in order to assess case and determine needs.
Give referral and/or make referral appointment as circumstances warrant.
Review for medical appropriateness psychiatric/substance abuse cases utilizing professional knowledge to apply Carelon Behavioral Health Options criteria and render certification decisions that are within the scope of practice that is relevant to the clinical area under review.
Provide reviews for predetermination of medical necessity.
Review proposed courses of treatment for medical necessity.
Utilize rounds and case consultations with Clinical Supervisor and Peer Advisor for cases outside the medical necessity criteria.
Interface with internal and external customers to maintain optimal efficiency of service.
Maintain telephone superior service standards.
Contribute to weekly staff meetings and clinical conferences.
Attend appropriate meetings, trainings and conference calls as scheduled.
Perform all other aspects of customer service as required.
Conduct business in a professional manner.
Troubleshoot claims issues.
Investigate and research to resolve customer complaint problems and issues.
Apply Carelon Behavioral Health Options policies and procedures consistently.
Maintain confidentiality of Clients, Business Records and Reports.
Maintain ethical and professional standards.
Maintain individual productivity and performance standards.
Meet Departmental expectations, accuracy, productivity, and performance standards.
Support Carelon Behavioral Health Options in achieving its Mission Statement.
Complete tasks accurately and within required timeframes.
Adhere to the components of the Compliance Program.
Ensure that job tasks are performed in a legal and ethical manner.
Actively assess work area for non-compliance issues and notify supervisor or call Ethics Hotline.
Adhere to compliance training requirements and understand that training is required condition of employment.