At Aetna Better Health of Texas, we are committed to helping people on their path to better health. By taking a total and connected approach to health, we guide and support our members so they can get more out of life, every day. We are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of Texas STAR Kids members. We value diversity and are dedicated to helping you achieve your career goals.
The Service Coordinator 1, (Clinical Case Manager BH) is a field-based position responsible for conducting face to face assessments. Candidates may reside in any of these or adjacent counties: Collin, Dallas, Ellis, Hurt, Kaufman, Navarro, and Rockwall. 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 requires routine travel in the Dallas service area, 80-90% of the time. Some travel to the Dallas office, support location, may also be required. Use of personal vehicle when traveling in the field; must have active and valid TX driver's license, reliable transportation and vehicle insurance. Business mileage is eligible for reimbursement, in accordance with travel policy guidelines.
Fundamental Components: Assessment of Members:
Through the use of clinical tools and information/data review, conducts comprehensive face to face assessments of referred member’s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member’s benefit plans 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.
Actively engage with providers and members during key transitions of care.
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 knowledgeably 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.
Reviews prior claims to address potential impact on current case management and eligibility.
Assessment includes the member's level of work capacity and related restrictions/limitations.
Monitoring, Evaluation and Documentation of Care:
In collaboration with the member and their care team develops and monitors established person-centered 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.
Minimum of 1 year previous service coordination or case management experience and experience with pediatric clients is required; integrated model experience is preferred
3+ years of direct clinical practice experience post-masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility required
Minimum of a Master's degree in Behavioral/Mental Health or related field
Unencumbered Behavioral Health clinical license in the state where they work required (i.e., LCSW, LPC, LMSW, etc.)
Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel. Strong keyboard and mouse skills required.
Working knowledge of care management principles preferred
Clinical Licensure: Licensed Clinical Social Worker (LCSW)
Potential Telework Position: Yes
Percent of Travel Required: 75 - 100%
EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer
Benefit Eligibility: Benefit eligibility may vary by position.
Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.