Job Summary:

This position is responsible for performing behavioral health duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new BH Clinicians and other staff as needed during the performance of their daily job duties.Responsibilities:

• Assesses patient's behavioral health clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Additionally, where applicable, ensure that the services provided are medically appropriate to member's needs, aligned with the benefit structure, and that they have the appropriate supports to be successful with their treatment.

• Evaluates the necessity, appropriateness and efficiency of behavioral health medical services and procedures provided, for both acute and chronic health care needs when applicable.

• Develops, coordinates and assists in implementation of plan for members and of individualized plan of care for members and identification of barriers towards Self- Management and optimal wellness.

• Demonstrates a high level of knowledge and understanding of the application of Milliman Care Guidelines (MCG) and American Association of Addiction Medicine (ASAM) criteria to medical necessity criteria.

• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and coordinates internally for negotiation of fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care, including transitional care where applicable.

• Monitors patient's behavioral health medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

• Encourages member participation and compliance in the behavioral health case/disease management program efforts.

• Documents accurately and comprehensively based on the standards of practice and current organization policies.

• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.

• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

• Serves as mentor/trainer to new BH Clinicians and other staff on an ongoing basis.

• Serves as an escalation point for cases and issues that require additional attention.

• Coordinates the implementation of clinical process improvement with the support of the team supervisor.

• Works independently on special projects in conjunction with the supervisor that support the needs of the business.

• Provides feedback and collaborates with department supervisor in evaluating areas of needed improvement within the team.

• Completes other assigned functions as requested by management.

• Works independently on complex cases.

• Recommend workflow and process improvements

• Execute UAT test cases thoroughly from end to end.

• Required to work one holiday shift per year.

Addendum for Navigation roles:

• Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider and assist member as well as facility with addressing the needed provider resources to decrease identified gaps in care.

• Presents clinical cases during audits conducted by external review organizations.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Salary Range:

$76,800 - $102,795

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.