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Req ID: 64910BR
The Behavioral Health Clinical Care Manager is responsible for assessing members face-to-face and telephonically; and planning, implementing and coordinating all case management activities with members to evaluate the appropriate holistic needs (physical, psychological, social, financial, spiritual, residential) of the member to facilitate the member s overall wellness and care. In doing this the Clinical Care Manager develops a proactive course of action to address issues presented to enhance the short and long term outcomes as well as opportunities to enhance a member s overall wellness through integration. Services, strategies, policies and programs are comprised of network management and clinical coverage policies.
Routine field-based travel in Eastern WV with personal vehicle is a job requirement. Qualified candidates must have dependable transportation, valid state driver s license and proof of vehicle insurance.
Fundamental Components included but are not limited to:
Assessment of Members:
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member s benefit plan and available internal and external programs/services.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
Enhancement of Medical Appropriateness and Quality of Care:
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member s needs to ensure appropriate administration of benefits.
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes.
Identifies and escalates quality of care issues through established channels.
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
Helps member actively and knowledgeably participate with their provider in healthcare decision-making.
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
Monitoring, Evaluation and Documentation of Care:
In collaboration with the member and their care team develops and monitors established plans of care to meet the member s goals.
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
Qualifications Requirements and Preferences:
3+ years of direct clinical practice experience post masters degree (e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility) required.
Minimum of a Master's degree in Behavioral/Mental Health or related field required.
Unencumbered Behavioral Health clinical license for State of WV required.
Examples of acceptable licensure: LCSW, LGSW, LICSW
Ability to speak to medical and behavioral health professionals to influence appropriate member care required.
Crisis intervention skills preferred.
Managed Care/utilization review experience preferred.
Case management and discharge planning experience preferred.
Mental Health - Licensed Clinical Social Worker, Mental Health - Licensed Independent Social Worker, Mental Health - Licensed Professional Counselor
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts
Benefits Management - Interacting with Medical Professionals, General Business - Communicating for Impact, General Business - Consulting for Solutions
Additional Job Information:
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Healthcare
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.
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