Clinical Case Manager, Behavioral Health

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 prioritise 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.

Position Summary:

Utilises advanced clinical judgement and critical thinking skills to facilitate appropriate member physical health and behavioural healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilisation of available resources and optimal, cost‑effective outcomes.

Assessment of Members:

• Through the use of clinical tools and information/data review, conducts 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 programmes/services.

• Applies clinical judgement 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, performs crisis intervention with members experiencing a behavioural health or medical 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/services.

Enhancement of Medical Appropriateness and Quality of Care:

• Application and/or interpretation of applicable criteria and clinical guidelines, standardised case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits

• Using holistic approach consults with supervisors, Medical Directors and/or other programmes 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 behavioural health professionals to influence appropriate member care.

• Utilises influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behaviour changes to achieve optimum level of health

• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.

• Helps member actively and knowingly participate with their provider in healthcare decision‑making

• Analyzes all utilisation, self‑report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Monitoring, Evaluation and Documentation of Care

• In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals

• Utilises case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

• Ability to take and manage crisis calls.

Required Qualifications:

• Unencumbered Independent Behavioural Health clinical licence in the state where they reside and work:

Licensed Mental Health Counselor (LMHC)

Licensed Clinical Social Worker (LCSW)

Licensed Independent Social Worker (LISW)

Licensed Marital and Family Therapist (LMFT)

Licensed Professional Counselor (LPC)

• 3+ years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility

• 3+ years minimum of Behavioural Health experience

• Applicants must be willing to work standard business hours in EST or CST.

Preferred Qualifications

• Case management and discharge planning experience

• Crisis intervention skills

• Managed care/utilisation review experience

• Ability to take and manage crisis calls

Education

Minimum of a…