Clinician II

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Evaluate the behavioral health clinical needs of patients based on established guidelines and standards to ascertain the medically suitable level of care and duration of stay.

• Assess the necessity, appropriateness, and efficiency of behavioral health medical services and procedures.

• Create, coordinate, and aid in the implementation of personalized care plans for members while identifying obstacles to self-management and wellness.

• Utilize Milliman Care Guidelines (MCG) and American Association of Addiction Medicine (ASAM) criteria.

• Oversee and coordinate out-of-network and out-of-area services, negotiating fees when applicable.

• Collaborate with patients, families, healthcare providers, hospitals, and external customers regarding care appropriateness from diagnosis through to outcomes.

• Ensure high-quality, cost-effective care throughout the continuum, including transitional care.

• Monitor behavioral health care activities and outcomes for suitability and efficacy.

• Advocate for members and their families across different care settings.

• Promote member engagement and adherence to behavioral health case/disease management programs.

• Accurately document information in accordance with practice standards and organizational protocols.

• Communicate with multidisciplinary teams either via telephone or in person.

• Assess care, analyze discrepancies, and take part in quality improvement initiatives.

• Mentor and train new behavioral health clinicians and other staff members.

• Act as an escalation point for intricate cases and issues.

• Coordinate clinical process enhancements in conjunction with the team supervisor.

• Work autonomously on special projects and complex cases.

• Suggest improvements to workflows and processes.

• Conduct end-to-end execution of UAT test cases.

• Participate in one holiday shift annually.

• For Navigation roles, address care gaps and high-risk members, collaborate with providers, and present clinical cases during external audits.

• For BH Clinical Advocate roles, perform member outreach, apply clinical expertise, utilize Motivational Interviewing, explain ASO benefits, and educate members on navigating the healthcare system.

• Work an 8- or 10-hour schedule from Monday to Friday, with operating hours ranging from 8 AM to 8 PM EST.

• Travel to office locations as needed for BH Clinical Advocate roles.

⛳️ Requirements

• High School Diploma or GED is mandatory.

• A bachelor's degree in a behavioral health-related field or a nursing degree is preferred, or relevant experience may be accepted in lieu of a degree.

• A master's degree in a behavioral health-related field or a nursing degree is preferred.

• A minimum of 2 years of clinical experience in behavioral health is required.

• At least 1 year of behavioral health experience in a managed care setting or the health insurance industry is necessary.

• An active, unrestricted NJ LCSW, LMFT, LPC, LBA, or RN License is required.

• CCM Certification is preferred for BH Clinical Advocate roles.

• Proficiency in using personal computers and related software in a Windows environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes is preferred.

• Familiarity with intranet and internet applications is preferred.

• A working knowledge of case/care management principles is preferred.

• Understanding of utilization management principles is preferred.

• Basic knowledge of healthcare contracts and benefit eligibility criteria is preferred.

• Knowledge of hospital structures and payment systems is preferred.

• Bilingual proficiency is preferred for BH Clinical Advocate roles.

• For field-based positions, 100% travel is required.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement