Behavioral Health Liaison - Work From Home

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The Behavioral Health Liaison directs coordination of care between the Aetna benefits member, clinical care teams, and providers. The Behavioral Health Liaison conducts both live member outreach calls along with provider education initiatives that support the development of HEDIS interventions to improve mental health wellness and outcomes. The Behavioral Health Liaison develops and implements data-driven strategies and interventions that ensure the delivery of time‑sensitive behavioral health benefits and services for members.

This role takes part in the analysis and reporting of member data to monitor outreach effectiveness. The Behavioral Health Liaison reviews documentation and interprets data obtained from clinical records or internal systems to apply appropriate clinical criteria and policies in line with HEDIS, regulatory, and accreditation requirements. This position coordinates behavioral health care and other needs with internal/external clinician support as required including working with the Care Management and Utilization Management teams.

• Makes daily/weekly outbound calls to Aetna benefit members in need of behavioral health follow-up care from inpatient stays or Emergency Department visits
• Collaborates with various health management team members to develop specific interventions that will improve members’ health status, members adherence to care plan, and compliance with coordinated services.
• Support record collection and review of case and medical records for behavioral health quality activities, including root cause analysis of high utilizers of behavioral health services.
• Reviews documentation and evaluates potential quality of care/gap in care issues based on clinical policies and benefit determinations.
• Conducts outbound telephone calls to members regarding service compliance with behavioral health providers.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Offers consultant services and education to network providers to improve adherence to HEDIS standards of care and coding.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.

• Data gathering requires navigation through multiple system applications.

• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.

• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information for Quality Management audit purposes or coordination of member services.
• Local travel to network provider offices may be required.
• Pro‑actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.

• Three to five years of Clinical/Behavioral Health experience required.
• Case Management/Care Coordination skills preferred.
• Experience with in Managed Care preferred.
• Ability to build productive professional relationships and work collaboratively within cross‑functional team…