Nursing - Behavior Health Clinician 1

The Behavioral Health Case Manager assesses, coordinates, and monitors behavioral health services to ensure members receive appropriate, high-quality, and cost-effective care across the continuum.

1. Assess patients behavioral health clinical needs aProductst established guidelines and standards to determine appropriate level of care and length of stay for inpatient services.

2. Evaluate the necessity, appropriateness, and efficiency of behavioral health medical services and procedures.

3. Coordinate and assist with implementation of individualized care plans for members.

4. Monitor and coordinate out-of-network and out-of-area services, including internal coordination for fee negotiation when appropriate. Collaborate with patients, families, physicians, hospitals, and external partners to ensure appropriate care from diagnosis through outcomes.

5. Coordinate delivery of high-quality, cost-effective care in alignment with clinical practice guidelines across the full continuum of care.

6. Monitor behavioral health care activities and outcomes for appropriateness and effectiveness, regardless of site of service.

7. Advocate for members and families across care settings to optimize resource utilization and evaluate services provided.

8. Encourage member participation and compliance with behavioral health case and disease management programs.

9. Document care activities accurately and comprehensively in accordance with standards of practice and organizational policies.

10. Communicate and collaborate effectively with multidisciplinary teams via telephone and/or in person to ensure continuity and efficiency of care.

11. Demonstrate fiscal accountability and understanding of resource utilization and its impact on patient outcomes.

12. Evaluate care through problem-solving, variance analysis, and participation in quality improvement initiatives to enhance member outcomes.

13. Perform additional duties as assigned by management.

• Masters degree in a behavioral healthrelated field or a Nursing degree required

• Minimum of two (2) years of behavioral health clinical experience required

• Behavioral health experience in a managed care setting strongly preferred

• Active, unrestricted New Jersey license required (LCSW, LMFT, LPC, or RN)

• Proficiency with personal computers and Windows-based applications, including MS Word, Excel, PowerPoint, and Lotus Notes

• Familiarity with intranet and internet-based applications

• Working knowledge of case/care management principles

• Working knowledge of utilization management principles

• Basic understanding of healthcare contracts and benefit eligibility requirements

• Knowledge of hospital structures and reimbursement/payment systems