Care Plan Reviewer (OHRISE)

CVS Health

Job Overview

Job details

Job Type
Full-time

Full Job Description

This is a full time teleworker position in Ohio. The Care Plan Reviewer (Clinical Case Manager BH) 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 psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. Must reside in Ohio.

Fundamental Components:

  • Assessment of Members:

o 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 and ensures alignment with behavioral health services requested by providers on behalf of members
o 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.
o Makes linkages as appropriate to clinical providers as needed for members in crises and develop safety plans when clinically indicated
o Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.

  • Enhancement of Medical Appropriateness and Quality of Care:

o 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.
o 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.
o Helps member actively and knowledgably 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:

o 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.

Required Qualifications

  • Unencumbered Behavioral Health clinical license in the state where they work (Ohio) as a Licensed Mental Health Professional (i.e. LPC, LCSW, or equivalent)
  • 3+ years of direct clinical practice experience post Master’s degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility.
  • 2+ years of experience in children’s mental health, child welfare, developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers
  • Background and experience in one or more of the following areas of expertise: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development; and
  • Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems.
  • Demonstrated proficiency with personal computers, keyboard and multi-systems navigation, and MS Office Suite applications.

Preferred Qualifications

  • Crisis intervention skills.
  • Managed care/utilization review experience.
  • Case management and discharge planning experience.

Education

  • Minimum of a Master’s degree in Counseling, Social Work, or closely related field is required.

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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