Aetna Remote Jobs – Clinical Case Manager BH

Job Description:

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.

Job Responsibilities:

• 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.
• 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.
• Through the use of clinical tools and information/data review, ensure 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.
• Provides information and support to CMEs which empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Support and monitor crisis follow up to help ensure members are receiving the appropriate treatment/services.
• Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
• 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.
• Ensures members actively and knowledgably participate with their provider in healthcare decision-making.
• Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• Using advanced clinical skills, supports CME 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.
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.
• Identifies and escalates quality of care issues through established channels.

Job Requirements:

• Willing and able to travel up to 20% of the time in the assigned region. Must possess reliable transportation, valid/active driver’s license, and proof of vehicle insurance.
• Managed care/utilization review experience.
• Must reside in Ohio.
• 1+ year(s) of experience with personal computer, keyboard and multi-systems navigation, and MS Office Suite applications (Word, Outlook, Excel, SharePoint).
• Unencumbered Behavioral Health clinical license in Ohio. (LPCC/PCC, IMFT, LISW)
• Willing and able to work beyond core business hours of Monday-Friday, 8am-5pm.
• 3+ years of direct clinical practice experience post Master’s degree.
• Case management and discharge planning experience.
• 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.
• Crisis intervention skills.
• Masters degree in social work, counseling, or marriage and family therapy with an independent practice license in Ohio, LISW, LPCC, or IMFT required
• 2+ years of experience in children’s mental health, child welfare, developmental disabilities, juvenile justice, or a public sector human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers.

Job Details:

Company: Aetna

Vacancy Type:  Full Time

Job Location: Cincinnati, OH, US

Application Deadline: N/A

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