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Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is non-member facing remote role with a travel requirement of up to 10% for any regional meetings/trainings in the state of Ohio.

The hours for this position are Monday-Friday 8a-5p EST.

Position Summary

The Care Plan Reviewer (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.

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:

• 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.
• 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.
• 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.
• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
• Enhancement of Medical Appropriateness and Quality of Care:
• 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.
• 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.

• Identifies and escalates quality of care issues through established channels.

• Ability to speak to medical and behavioral health professionals to influence appropriate member care.

• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.

• Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.

• Helps member actively and knowledgably participate with their provider in healthcare decision-making.

• 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:

• In collaboration with the member and their care team develops and monitors established plans of care to meet the member's goals.
• Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Required Qualifications

• Must be Ohio Resident
• Active Behavioral Health license in the state of Ohio (ex: LMFT, LSW, LPC, LISW)
• 3+ years of direct clinical practice experience post-Master's degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
• 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers
• 2+ years of 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
• Willing and able to travel up to 10% for occasional regional trainings/meetings in the state of OH as need basis
• Willing to work standard business hours: Monday - Friday, 8am - 5pm EST
• 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, and MS Office Suite applications

Preferred Qualifications·

• Independent clinical license preferred: LPCC, IMFT, or LISW
• Managed care/utilization review experience
• Case management and discharge planning experience

Education

• Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy

Pay Range

The typical pay range for this role is:

$54,095.60 - $116,760.80

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.  
 
For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 10/24/2024

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.