The Clinical Care Manager is responsible for care coordination activities and collaboration with all stakeholders involved in a Members case. The Clinical Care Manager is responsible for utilization management by conducting utilization review activities, population management, cross-system consultation, and treatment quality monitoring. The Clinical Care Manager must utilize clinical knowledge of best practices and evidence-based treatments to ensure CBH members receive timely access to quality, medically necessary behavioral health services. When clinically indicated, Clinical Care Managers consult with CBH Physician and Psychologist Advisors to ensure the most effective treatment for the CBH member is being authorized.
Essential Functions:
- Be knowledgeable about behavioral health care services, system partners, service continuum and established medical necessity criteria and apply that knowledge in all work activities.
- Complete Utilization Management activities including but not limited to: interagency meetings, social determinants interviews with members, treatment team meetings, case consultations, care coordination, provider meetings, reviews, treatment linkage.
- Complete expected number of UM activities per day/shift as specified under team specified under team specific responsibilities in established timeframes.
- Authorize treatment when Medical Necessity Criteria is met.
- Consult with Physician Advisor, Psychologist Advisor and/or Clinical Leadership as clinically appropriate.
- Generate denial letters based on physician reviews and in accordance with state regulations as needed.
- Work directly with members, natural supports and providers in the community during at least 6 days per month.
- Facilitate care coordination with system partners to address social determinants, barriers to wellness, and other needs of members, including connection to appropriate community based services.
- Demonstrate an understanding of Evidence-Based Practices (EBPs) and connect members to appropriate evidence-based treatment at admission, during treatment, and at discharge.
- Monitor members length of treatment and work collaboratively with providers and other systems to address barriers to member receiving treatment in a less restrictive environment.
- Collaborate with other CBH departments to ensure quality of care, promote placement of members in the most appropriate services and to facilitate consistent longitudinal care management.
- Document provider quality concerns in accordance with CBH policy/procedure.
- Conduct provider and/or stakeholder meetings at least quarterly.
- Use data to inform clinical decision-making.
- Maintain documentation in CBHs electronic system consistent with agency and industry standards.
- Respond to care coordination correspondence within 24-48 hours or sooner if necessary.
- Work collaboratively with team members including assisting with the training of newly hired employees as requested, covering work when peers are out of the office as assigned and finding coverage when absent.
- Attend all meetings as assigned and actively prepare for and participate in supervision and clinical case consultations.
- Ensure highest quality of customer service when interacting with members, providers, and other stakeholders.
- Participate in grievance/complaint hearings as assigned.
- Display commitment to member and family driven care and principles of resiliency and recovery.
- Participate in NIAC preparation and site visits as needed.
- Maintain an accurate daily log of work completed.
- Contribute to projects and other duties as assigned.
Team Specific Responsibilities:
- Follows all NCQA Program guidelines as outlined in the program materials
- Completes an average of 5 -10 UM activities per day
- Facilitate care coordination with external entities including behavioral and physical health providers, Targeted Case Management (TCM), Transitions, Integration and Partnerships (TIP) Unit, Housing providers, Courts and Probation, Child Welfare, and School District of Philadelphia
- Address member engagement in treatment for assigned cohort by reporting or addressing any reported/observed quality concerns, resolving communication barriers between member and providers, assisting member with mediation issues/barriers, assisting with any clarification/prioritizing issues, increase positive collaboration with providers and other supports
- Facilitate longitudinal care management of special needs populations as assigned
Position Requirements:
- Education: Masters degree in Social Work or related field
- Clinical Licensure: Qualified candidates are required to obtain license within the first 18 months (1.5 years) of employment; PA Child Abuse Clearance required
- Required Licensure: Licensed Social Worker (LSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW
- Relevant Work Experience: Minimum of 3 years of direct clinical care experience working with adults, children, adolescents and/or their families in behavioral health settings and experience in assessment and treatment planning; and/or experience in a managed care setting
Skills:
- Excellent clinical case conceptualization skills
- Meeting facilitation
- Proactive planning
- Customer service
- Familiar with medications
- Excellent verbal and written communication skills and ability to use them when communicating with internal and external stakeholders.
- Excellent interpersonal and collaboration skills
- Proficient in MS Office, especially with Excel, and able to type at least 40 words per minute
- Ability to work independently and as part of a team
- Excellent time management and prioritization skills and ability to multi-task
- Compliant with HIPAA regulations
Work Conditions (including travel, overtime required, physical requirements and occupational exposure):
- Must be able to travel within Philadelphia and surrounding counties.
- Regularly requires walking, standing, stooping, bending, sitting, reaching, pushing, pulling and/or repetitive wrist/hand movements for various lengths of time throughout the day.
- Ability to utilize computers and office equipment to complete daily work responsibilities.
- Regularly works inside in areas that are adequately lighted and ventilated. Some fluctuation in temperature. No protective equipment routinely needed.
- Must be able to adapt to continuous changes/demands of the job.
Philadelphia Residency Requirement:
- The successful candidate must be a current Philadelphia resident or become a resident within six months of hire.
Equal Employment Opportunity:
- We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CBH is an equal opportunity employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on all qualified individuals. This is without regard to race, ethnicity, creed, color, religion, national origin, age, sex/gender, marital status, gender identity, sexual orientation, gender identity or expression, disability, protected veteran status, genetic information or any other characteristic protected individual genetic information, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function by applicable federal, state, or local law.
Requesting An Accommodation:
- CBH is committed to providing equal employment opportunities for individuals with disabilities or religious observance, including reasonable accommodation when needed. If you are hired by CBH and require an accommodation to perform the essential functions of your role, you will be asked to participate in our accommodation process. Accommodations made to facilitate the recruiting process are not a guarantee of future or continued accommodation once hired.
- If you would like to be considered for employment opportunities with CBH and have accommodation needs for a disability or religious observance, please send us an email at ...@Phila.gov
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