Clinical Case Manager

Position Summary

This is a Field based role requiring 75% travel to meet in-person with members around our service delivery area. The service delivery area includes areas to the West of Dallas. Between Dallas and Forth Worth in the Arlington area.

The Clinical Case Manager utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psycho social wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.

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.
• Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• 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.

Contact with Members:

• Through the use of service coordination 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.
• Completes face to face visits and monthly phone contact with members, utilizing various treatment modalities and interventions to achieve desired goals for members.
• Applies judgment to the incorporation of strategies designed to reduce risk factors and address indicators which impact care planning and resolution of member issues while aware of member diagnosis.
• Utilizes motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.

Required Qualifications:

• Direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
• Must possess reliable transportation and be willing and able to travel up to 75% of the time. Mileage is reimbursed per our company expense reimbursement policy. Travel in Tarrant or Dallas counties and surrounding areas
• Unencumbered Behavioral Health clinical license in the state where they work (LCSW, LPC, LMSW, LMFT)
• Case management and discharge planning experience preferred

Preferred Qualifications:

• Field Experience
• Bilingual
• Crisis intervention skills preferred
• Managed care/utilization review experience preferred

Education

• Master's degree in Behavioral/Mental Health or related fielded, degree being social work or counseling

Licensing

• Unencumbered Behavioral Health clinical license in the state where they work (LCSW, LPC, LMSW, LMFT)

Days and Hours

• Monday - Friday, 8:00am-5:00pm, may require flexibility outside these times based on member preference.