Clinical Care Manager II

Clinical Care Manager II

Shift: Sunday 7:00am - 3:30pm EST and Monday - Thursday 2:00am - 10:30am EST

Location: Dearborn, MI

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

For associates who are subject to a collective bargaining agreement (CBA): where this guidance is inconsistent with the CBA, the CBA provisions will prevail.

The Clinical Care Manager II provides assessments, referrals, and counseling. Conducts telephone assessments, collecting sufficient clinical information to make appropriate referral and certification decisions for emergency/urgent referrals that require alternate levels of care. Makes appropriate certification decisions. Collaborates with providers to determine alternate levels of care and to facilitate transfers to network facilities and providers whenever possible. Facilitates coordination of care with other managers to assure continuity of care. Evaluates clinical appropriateness of treatment using professional knowledge within Carelon Behavioral Health clinical and work site guidelines and renders certification decisions or seeks consultations for non-certification decisions. Directs members to an appropriate therapist or EAP provider and reviews care on a regular basis to determine whether treatment meets Carelon Behavioral Health criteria for medical necessity. Refers cases to an MD or Clinical Management staff if unable to determine that medical necessity criteria have been met. Establish and deliver knowledge about care resources and levels of care availability. Special projects and all other duties as assigned.

How you will make an impact:

Primary duties may include, but are not limited to:

• Complete telephone assessments and referral; gathers demographic and clinical information to connect patient with appropriate provider, including outpatient treatment as necessary; and for emergency, urgent, routine and EAP referrals.
• Provide appropriate referrals for treatment based on assessment of information gathered during telephone contacts and or on-site with providers.
• Refer cases that do not meet criteria and need non-cert., to Peer Advisors.
• Manage release of MHSA benefit provided by carrier for designated group.
• Ask questions and listen to member in order to assess case and determine needs.
• Give referral and/or make referral appointment as circumstances warrant.
• Review for medical appropriateness psychiatric/substance abuse cases utilizing professional knowledge to apply Carelon Behavioral Health criteria and render certification decisions that are within the scope of practice that is relevant to the clinical area under review.
• Provide reviews for predetermination of medical necessity.
• Review proposed courses of treatment for medical necessity.
• Interface with internal and external customers to maintain optimal efficiency of service.
• Maintain telephone superior service standards.
• Contribute to weekly staff meetings and clinical conferences.
• Attend appropriate meetings, trainings and conference calls as scheduled.
• Perform all other aspects of customer service as required.
• Conduct business in a professional manner.
• Troubleshoot claims issues.
• Investigate and research to resolve customer complaint problems and issues.
• Apply Carelon Behavioral Health policies and procedures consistently.
• Maintain confidentiality of Clients, Business Records and Reports.
• Maintain ethical and professional standards.
• Maintain individual productivity and performance standards.
• Meet Departmental expectations, accuracy, productivity, and performance standards.
• Support Carelon Behavioral Health in achieving its Mission Statement.
• Complete tasks accurately and within required timeframes.
• Adhere to the components of the Compliance Program.
• Ensure that job tasks are performed in a legal and ethical manner.
• Actively assess work area for non-compliance issues and notify supervisor or call Ethics Hotline.
• Adhere to compliance training requirements and understand that training is required condition of employment.

Minimum Requirements:

• Master's degree in social work, psychology, counseling or a Bachelor's level RN. Licenses: Current, valid and unrestricted license in the State of Michigan in a mental health field (RN, Ph.D., LCSW/ACSW, LLP, MHC, LPC, etc.).
• A minimum of 3 years' experience in psychiatric or substance abuse treatment.
• Experience as a CEAP or EAP internal/external consultant to a work site area required (for the integrated unit only), or a minimum of 2 years' experience, prior to licensure with Carelon Behavioral Health Clinical Operations Unit functioning as a Clinical Support Specialist with required licensure activities supervised by the Clinical Manager or Clinical Director.

Preferred Qualifications:

• Experience in settings that include inpatient, partial, and/or outpatient care preferred.

Job Level: Non-Management Exempt

Workshift: 3rd Shift (United States of America)

Job Family: UNN > Union 061

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.