Care Plan Reviewer- OhioRISE

Care Plan Reviewer (Clinical Case Manager BH) We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. The Care Plan Reviewer (Clinical Case Manager BH) utilizes advanced clinical judgment and critical thinking skills to supports appropriate member behavioral healthcare through review of assessment and care planning documentation and consultation with care coordinators to support psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. As part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems. Responsibilities include: Be clinically and culturally competent/responsive with training and experience necessary to provide clinical consultation for members complex need across child-serving systems. Assessment of Member's Child and Family-Centered Care Plans and Crisis and Safety Plan: Through the use of clinical tools and information/data review, review assessments of member's needs and determines approach to meeting needs by evaluating comprehensiveness of member's Child and Family-Centered Care Plans. 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, review crisis and safety plans for members experiencing a behavioral health need to support appropriate individualized trauma-informed interventions and de-escalation strategies. Enhancement of Medical Appropriateness and Quality of Care: Application and/or interpretation of applicable criteria and clinical guidelines, policies, procedures, and regulatory standards while completing reviews and prior approvals to assess member's needs to ensure timely 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 motivational interviewing skills to provide coaching to care coordination staff and supervisors to support the child and family-centered care planning process consistent with System of Care Principles and High-Fidelity Wraparound practice. Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs. Required Qualifications: Unencumbered Behavioral Health clinical license in Ohio is required (LMFT, LSW, LPC). 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers. 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. 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, and MS Office Suite applications. Preferred Qualifications: LPCC, IMFT, LISW licenses are preferred. 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. Managed care/utilization review experience. Case management and discharge planning experience Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy is required Anticipated Weekly Hours: 40 Time Type: Full time Pay Range: The typical pay range for this role is: $60,522.00 - $129,615.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 09/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. CVS Health