Nurse Case Manager II - Behavioral Health Case Manager - Texas

Job Responsibilities Responsible for telephonic and/or face to face assessment, planning, implementing and coordinating care management activities with members to ensure that their medical and behavioral health needs are met and to enhance the member’s overall wellness. Develop a proactive course of action to address issues presented and facilitate short and long-term outcomes as well as identify opportunities to enhance a member’s overall health through integration. Using clinical tools and data review, conducts comprehensive assessments of members’ needs and recommends an approach to case resolution by meeting needs in alignment with their benefit plan and available internal and external programs and services. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical and social indicators which impact care planning and resolution of member issues. Completes assessments that consider information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality and the member’s restrictions/limitations. Analyzes utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs. Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health 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 and services. Applies and interprets 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. Serves as a single point of contact for members and assists members to remediate immediate and acute gaps in care and access. Using holistic approach consults with managers, medical directors and/or other physical/behavioral health support staff and providers to overcome barriers to meeting goals and objectives. Presents cases at case conferences/rounds to obtain multidisciplinary view in order to achieve optimal outcomes. Works collaboratively with the members’ interdisciplinary care team. 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 discern their health status and health needs based on key questions and conversation. Provides coaching, information and support to empower the members to make ongoing independent medical and/or healthy lifestyle choices. Helps members actively and knowledgably participate with their provider in healthcare decision-making. 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. Facilitates clinical hand-offs during transitions of care. Skills 3-5 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’ experience using personal computers, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.) Crisis intervention skills Managed care/utilization review experience preferred Case management and discharge planning experience preferred Experience providing care to Indigenous/Native American population preferred Education/Experience Minimum of a Master’s Degree In Behavioral/ Mental Health or related field Unencumbered Behavioral Health clinical license in the state of Illinois – licensed mental health professional - Licensed Professional Counselor (LPC), Licensed Marriage &; Family Therapist (LMFT), Licensed Behavioral Practitioner (LFP), or Licensed Clinical Social Worker (LCSW) with current unencumbered license Successfully complete the Behavioral Health Case Manager certification training provided through the Department of Mental Health and Substance Abuse Services within 6 months of hire date #J-18808-Ljbffr SGS Consulting