Clinical Case Manager Behavioral Health Job at CVS Health (Work at Home)

Integrated Care Manager

Responsible for promoting continuity of care through a collaborative process tha...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN
Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications
Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC).

Job Responsibility

Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan
Answer a diverse and high volume of health insurance related customer calls on a daily basis
Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements
Maintain complete and accurate records per department policy
Demonstrate ability to apply plan policies and procedures effectively

Fulltime

Case Manager, Registered Nurse

Remote case manager position working intensely as a telephonic case manager with...

Location

United States , Remote

Salary:

54095.00 - 155538.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

5+ years’ experience as a Registered Nurse
1+ year of experience in a hospital setting
Active, unrestricted RN license in state of residence
Willingness to receive multi-state/compact privileges
1+ years' experience documenting electronically using a keyboard
1+ years' current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics experience

Job Responsibility

Work as a telephonic case manager with patients and their care team
Application and/or interpretation of applicable criteria and clinical guidelines
Assess benefits and/or member's needs to ensure appropriate administration of benefits
Incorporate strategies designed to reduce risk factors and barriers
Address complex health and social indicators which impact care planning
Consult with supervisor and others in overcoming barriers
Utilize case management processes in compliance with regulatory requirements
Utilize motivational interviewing skills for member engagement
Identify and escalate member's needs appropriately
Actively reach out to members to collaborate/guide their care

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules

Fulltime

Behavioral Health Medical Director

The Behavioral Health (BH) Medical Director leverages clinical expertise to prov...

Location

United States

Salary:

189600.00 - 237000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

MD or DO degree and 5+ years of direct clinical patient care experience post residency or fellowship including behavioral health environments
Current and ongoing Board Certification in psychiatry by the American Board of Psychiatry and Neurology (ABPN) required
Additional Board Certification in Child and Adolescent Psychiatry or Addiction Medicine
A current and unrestricted license in the state of California and willing to obtain additional license(s)
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
Minimum 5 years of Utilization Review or Hospital experience required
Minimum 3 years of compliance related experience preferred
Managed Care experience preferred in utilization review and case management
Expertise in behavioral health case management, utilization review and telehealth delivery
Ability to design and evaluate behavioral health programs, integrating evidence-based practices and holistic wellbeing approaches

Job Responsibility

Oversee and participate in behavioral health case management, including utilization review, telephonic care, and urgent response coordination for behavioral health and substance use disorder needs
Conduct reviews for medical necessity for prior authorization, continued stay, and post-service claims, applying medical policy, guidelines, and current research
Integrate behavioral health screening and interventions within physical health case management programs, utilizing standardized tools (e.g., PHQ2, PHQ9) and ensuring appropriate referrals
Support and monitor virtual behavioral health services, ensuring access, privacy, and continuity of care for all age groups, including children, teens, and adults
Supervise and provide clinical oversight for residential and outpatient behavioral health programs, including partial hospitalization and intensive outpatient services, with an emphasis on family engagement and comprehensive discharge planning
Lead the development and implementation of comprehensive behavioral health strategies, including program design, staff education, and quality improvement initiatives
Maintain compliance with national guidelines (e.g., MCG, InterQual, specialty college recommendations) and regulatory requirements (federal, state, ERISA) specific to behavioral health
Oversee the negotiation and implementation of cost management strategies to affect quality outcomes, reflecting data in monthly case management reviews
Participate in grievance and appeals processes, including escalated behavioral health issues
Collaborate with the VP of Care Management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives

What we offer

Comprehensive medical and dental coverage through our own health solutions
Mental health support and wellness programs designed by experts who get it
Flexible work arrangements that fit your life
Retirement planning support to help you build real wealth for the future
Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage
Professional development opportunities and clear career progression paths
Mentorship from industry leaders who want to see you succeed
Learning budget to invest in skills that matter to your future
Unlimited PTO policy

Parttime

Rare Condition Manager

To support high-quality, cost-effective care by coordinating services for member...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Associate’s Degree in general field of study or Post High School Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate skill in word processing, spreadsheet, and database software
Maintain confidentiality and privacy
Advanced and current clinical knowledge
Practice interpersonal and active listening skills to achieve customer satisfaction
Interpret and translate policies, procedures, programs, and guidelines

Job Responsibility

Perform assessments, condition management education, training, and other clinically-based activities to coordinate care among providers, members, and family to implement the care plan
Make and answer a diverse and high volume of condition management-related member calls on a daily basis
Identify holistic member needs considering whole-person health, to include condition-specific needs, behavioral health needs, and social drivers of health needs
Analyze medical records, claims data, and other information sources
Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, BCBSAZ programs, provider networks, etc
Present status reports on cases to the manager/supervisor and, when indicated, to the medical director
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements
Maintain complete and accurate records per department policy

Fulltime

Integrated Care Manager - Adult

Responsible for promoting continuity of care through a collaborative process tha...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN
Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications
Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC)
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate skill in word processing, spreadsheet, and database software
Maintain confidentiality and privacy
Advanced and current clinical knowledge

Job Responsibility

Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan
Answer a diverse and high volume of health insurance related customer calls on a daily basis
Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests
Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements
Maintain complete and accurate records per department policy
Demonstrate ability to apply plan policies and procedures effectively

Fulltime

New