Behavioral Health Case Manager East TN and West TN
Company Name:
UniCare Life & Health Insurance Company
Job Description
Amerigroup , a proud member of the WellPoint family of companies, is focused on serving Medicaid, Medicare and uninsured individuals and families. We improve access to quality health care for the financially vulnerable, seniors and people with disabilities.
Here, you can do work that matters and offers opportunities for personal and professional growth. Together, our associates are transforming health care with trusted and caring solutions.
_Behavioral Health Case Manager_
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy, clinical criteria, and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Conducts pre-certification, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensures member access to medically necessary, quality healthcare in a cost effective setting according to contract.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers to assess member needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Job Qualifications
Requires a Master's degree in a related field or an RN;3 years of direct psychiatric and/or substance abuse experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted license as an RN, LPC, LCSW, LMFT, LAPSW, or LMSW is required. 3 years of experience with IDD and/or Community Mental Healthcare is preferred.
_WellPoint is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine, and is a 2013 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at_ _. EOE. M/F/Disability/Veteran.___
Once an offer is accepted, all external applicants are subject to a background investigation and if appropriate, drug testing. Offers of employment shall be contingent upon passing both the background investigation and drug testing (if required).
Current WellPoint associates: All referrals must be submitted through the formal associate referral process on WorkNet. Official guidelines for the associate referral program can be found in My HR.Estimated Salary: $20 to $28 per hour based on qualifications.
UniCare Life & Health Insurance Company
Job Description
Amerigroup , a proud member of the WellPoint family of companies, is focused on serving Medicaid, Medicare and uninsured individuals and families. We improve access to quality health care for the financially vulnerable, seniors and people with disabilities.
Here, you can do work that matters and offers opportunities for personal and professional growth. Together, our associates are transforming health care with trusted and caring solutions.
_Behavioral Health Case Manager_
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy, clinical criteria, and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
Works with medical directors in interpreting appropriateness of care and accurate claims payment.
May also manage appeals for services denied.
Conducts pre-certification, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensures member access to medically necessary, quality healthcare in a cost effective setting according to contract.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers to assess member needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Job Qualifications
Requires a Master's degree in a related field or an RN;3 years of direct psychiatric and/or substance abuse experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted license as an RN, LPC, LCSW, LMFT, LAPSW, or LMSW is required. 3 years of experience with IDD and/or Community Mental Healthcare is preferred.
_WellPoint is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine, and is a 2013 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at_ _. EOE. M/F/Disability/Veteran.___
Once an offer is accepted, all external applicants are subject to a background investigation and if appropriate, drug testing. Offers of employment shall be contingent upon passing both the background investigation and drug testing (if required).
Current WellPoint associates: All referrals must be submitted through the formal associate referral process on WorkNet. Official guidelines for the associate referral program can be found in My HR.Estimated Salary: $20 to $28 per hour based on qualifications.
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