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Job Description
Business Overview
As part of the bold vision to deliver the âœNext 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.

This is a full time telework position in Ohio, with travel required. The Clinical Case Manager BH utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. This position will support and work closely with Care Management Entities (CME) in the assigned region. Travel will be required to CME offices and other member locations within the assigned region. Additional responsibilities will include auditing and supporting data exchange for CME oversight.


Fundamental Components:

⢠Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems.

⢠Assessment of Members:
o 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
programs/services.
o 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.
o Using advanced clinical skills, performs crisis intervention
with members experiencing a behavioral health or medical
crisis and refers them to the appropriate clinical providers
for thorough assessment and treatment, as clinically
indicated.
o Provides crisis follow up to members to help ensure they
are receiving the appropriate treatment/services.
⢠Enhancement of Medical Appropriateness and Quality of Care:
o 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.
o 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.
o Identifies and escalates quality of care issues through established channels.
o Ability to speak to medical and behavioral health professionals to influence appropriate member care.
o Utilizes motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.
o Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
o Helps member actively and knowledgably participate with their provider in healthcare decision-making.
o Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.
⢠Monitoring, Evaluation and Documentation of Care:
o In collaboration with the member and their care team develops and monitors established plans of care to meet the member's goals.
o Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications
⢠Must reside in Ohio.
⢠Unencumbered Behavioral Health clinical license in Ohio. (LPCC, LPCC-S, IMFT, IMFT-S, LISW, OR LISW-S)
⢠3+ years of direct clinical practice experience post Master's degree.
⢠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.
⢠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.
⢠1+ year(s) of experience with personal computer, keyboard and multi-systems navigation, and MS Office Suite applications (Word, Outlook, Excel, SharePoint).
⢠Willing and able to travel up to 20% of the time in the assigned region. Must possess reliable transportation, valid/active driverâ™s license, and proof of vehicle insurance.
⢠Willing and able to work beyond core business hours of Monday-Friday, 8am-5pm.

COVID Requirements
CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.

If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications
⢠Crisis intervention skills.
⢠Managed care/utilization review experience.
⢠Case management and discharge planning experience.

Education
⢠Masters degree in social work, counseling, or marriage and family therapy with an independent practice license in Ohio, LISW, LPCC, or IMFT required

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.