The Clinical Care Manager is responsible for utilization management by conducting utilization review activities, population management, cross-system consultation, provider management and treatment quality monitoring. The Clinical Care Manager must utilize clinical knowledge of best practices and evidence based treatments to ensure CBH members receive timely access to quality, medically necessary behavioral health services. When clinically indicated, Clinical Care Managers consult with CBH Physician and Psychologist Advisors to ensure the most effective treatment for the CBH member is being authorized.
- Be knowledgeable about behavioral health care services, system partners, service continuum and established medical necessity criteria and apply that knowledge in all work activities.
- Complete Utilization Management activities including but not limited to: interagency meetings, social determinants interviews with members, treatment team meetings, case consultations, care coordination, provider meetings, reviews, treatment linkage.
- Complete expected number of UM activities per day/shift as specified under team specified under team specific responsibilities in established timeframes.
- Authorize treatment when Medical Necessity Criteria is met.
- Consult with Physician Advisor, Psychologist Advisor and/or Clinical Leadership as clinically appropriate.
- Generate denial letters based on physician reviews and in accordance with state regulations as needed.
- Work directly with members, natural supports and providers in the community during at least 6 days per month.
- Facilitate care coordination with system partners to address social determinants, barriers to wellness, and other needs of members, including connection to appropriate community based services.
- Demonstrate an understanding of Evidence-Based Practices (EBPs) and connect members to appropriate evidence-based treatment at admission, during treatment, and at discharge.
- Monitor member’s length of treatment and work collaboratively with providers and other systems to address barriers to member receiving treatment in a less restrictive environment.
- Collaborate with other CBH departments to ensure quality of care, promote placement of members in the most appropriate services and to facilitate consistent longitudinal care management.
- Document provider quality concerns in accordance with CBH policy/procedure.
- Conduct provider and/or stakeholder meetings at least quarterly.
- Use data to inform clinical decision-making.
- Maintain documentation in CBH’s electronic system consistent with agency and industry standards.
- Respond to care coordination correspondence within 24-48 hours or sooner if necessary.
- Work collaboratively with team members including assisting with the training of newly hired employees as requested, covering work when peers are out of the office as assigned and finding coverage when absent.
- Attend all meetings as assigned and actively prepare for and participate in supervision and clinical case consultations.
- Ensure highest quality of customer service when interacting with members, providers, and other stakeholders.
- Participate in grievance/complaint hearings as assigned.
- Display commitment to member and family driven care and principles of resiliency and recovery.
- Participate in NIAC preparation and site visits as needed.
- Maintain an accurate daily log of work completed.
- Contribute to projects and other duties as assigned.
Team Specific Responsibilities:
- Maintain a partner-focused approach with assigned providers.
- Facilitate/engage in provider meetings, site visits, and additional meetings on a quarterly basis.
- Develop proficiency with UM and care management strategies, with specific focus on FBS, FFT,
MST-PSB, and Early Childhood levels of care.
- Complete an average of 10-12 UM activities per day.
- Complete on site and/or telephonic reviews and consultation according to CCBS Team utilization management guidelines.
- Complete packet reviews as assigned, including review of packet documentation, Physician consultation per Review Guidelines, provider notification, referral submission (if required), denial letter (if required), authorization generation (if required), and log of review.
- Complete crisis consultations and help facilitate collaboration with community-based treatment team for members experiencing a crisis.
- Maintain documentation of daily utilization management activities using MCO (and/or SharePoint).
- Monitor caseload using level of care tracking grid, maintain and keeping grid updated on weekly basis.
- Conduct member outreach calls as needed.
- Participate in care coordination activities such as interagency meetings, discharge planning meetings with members, their family, provider(s), systems partners, supporting community tenure, and ensuring collaboration and continuity of care for members with multiple services or in multiple child-serving systems.
- Actively participate in weekly prevention rounds to review clinical and system challenges that impact members who are authorized for FBS, FFT, MST-PSB, or EC levels of care
- Actively participate in team meetings, trainings, individual and group supervision according to CBH policy and CCBS Team protocol.
- Education: Master’s degree in Social Work or related field or Registered Nurse
- License/Certification: License eligible and willing/able to obtain licensure within the first year of employment; PA Child Abuse Clearance required
- Preferred Licensure: Licensed Social Worker (LSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW)
- Relevant Work Experience: Minimum of 3 years of direct clinical care experience working with adults, children, adolescents and/or their families in behavioral health settings and experience in assessment and treatment planning; and/or experience in a managed care setting.
- Excellent clinical case conceptualization skills
- Meeting facilitation
- Proactive planning
- Customer service
- Familiar with medications
- Excellent verbal and written communication skills and ability to use them when communicating with internal and external stakeholders.
- Excellent interpersonal and collaboration skills
- Proficient in MS Office, especially with Excel, and able to type at least 40 words per minute
- Ability to work independently and as part of a team
- Excellent time management and prioritization skills and ability to multi-task
- Compliant with HIPAA regulations
Equal Employment Opportunity: CBH provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, gender identity, sexual orientation, individual genetic information or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function.
Americans with Disabilities Act: Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. CBH will determine reasonable accommodation on a case-by-case basis in accordance with applicable law.
This job profile reflects management’s assignment of current duties, responsibilities, and essential functions; it does not prescribe all or restrict the tasks that may be assigned now, or in the future, relevant to the responsibilities for this position. Community Behavioral Health (CBH) may change the specific job duties with or without prior notice based on the needs of the organization.