Care Manager Behavioral Health-4

Job ID: J127130
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Aug 1, 2018

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Description

JOB SUMMARY

This job implements the effective utilization management strategies including:  review of appropriateness of Healthcare services, application of criteria to assure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues.  Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction.  Responds to customer inquiries and offers interventions and/or alternatives.

ESSENTIAL RESPONSIBILITIES: 

  • Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.  Effectively function in accordance with applicable state, federal laws and regulatory compliance.
  • Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.  Promote quality and efficiency in the delivery of care management services.
  • Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework  of applicable laws.  Practice within the scope of ethical principles.
  • Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.  Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes.  Is familiar with the various care options and provider resources available to the member.
  • Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.  Develop and sustain positive working relationships with internal and external customers.
  • Utilize outcomes data to improve ongoing care management services.
  • Other duties as assigned or requested.

EDUCATION

Required

  • High School Diploma/GED with RN license

Or

  • Master's Degree if Licensed Behavioral Health Professional

Substitutions

  • None

Preferred

  • Bachelor’s Degree in Nursing

EXPERIENCE

Required

  • 3 - 5 years of post licensure experience in a combination of behavioral Health Clinical, Case Management and/or Condition Management
  • Experience in a clinical setting

Preferred 

  • Experience in UM/CM/QA/Managed Care

LICENSES AND CERTIFICATIONS

Required

Current license in one or more of the following disciplines:

  • Licensed Social Worker (LSW)
  • Licensed Clinical Social Worker (LCSW)
  • Licensed Professional Counselor (LPC)
  • Licensed Marriage and Family Therapist (LMFT)
  • Registered Nurse or Licensed Behavior Specialist

Preferred

  • Certification in Utilization Management or a related field

SKILLS

Required

  • Working knowledge of pertinent regulatory and compliance guidelines and medical policies
  • Ability to multi task and perform in a fast paced and often intense environment
  • Excellent written and verbal communication skills
  • Ability to analyze data, measure outcomes, and develop action plans
  • Be enthusiastic, innovative, and flexible
  • Be a team player who possesses strong analytical and organizational skills
  • Demonstrated ability to prioritize work demands and meet deadlines
  • Excellent computer and software knowledge and skills

Preferred

  • None

Language (Other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Office-Based Positions
The employee, either for an office or work from home arrangement, generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours, including weekends and nights to provide coverage.

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Frequently

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Rarely

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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