Care Plan Reviewer OhioRISE

Job DescriptionQualifying candidates may be eligible for a sign-on bonus of up to $5,000.Business OverviewAs part of the bold vision to deliver the "Next Generation" of managed care in Ohio Medicaid, OhioRISE 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.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 the care plan review, r coordination/collaboration with Care Management Entities (CME) and Care Coordinators, including the incorporation of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. Must reside in Ohio.Fundamental components:o Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems. o Through the use of clinical tools and information/data review, conducts comprehensive reviews of referred member's Care Plan 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 Ensures the Care Plan includes a well developed safety plan for use for members in crisis 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 member Care Plans and/or member's needs to ensure appropriate administration of member Care Plans.o 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. o Identifies and escalates quality of care issues through established channels.o Ability to speak to medical and behavioral health professionals to influence appropriate member care.o Utilizes influencing/motivational interviewing skills to ensure maximum engagement with CME and Care Coordinators to promote optimum level of health of Care Plan completion and executiono Promotes the member to actively and knowledgably participate with their CME and Care Coordinator in their Care Plan development and decision-making.o 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 CME and the care team monitors established plans of care to meet the member's goals.o 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 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. Willing and able to travel in-state up to 10% of the time with a personal vehicle. Must have reliable transportation, valid Ohio drivers' license, and proof of vehicle insurance. Willing and able to work beyond core business hours of Monday-Friday, 8am-5pm, is required.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.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.Education Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy is required.Business OverviewAt 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.

Created: 2024-10-19