Anthem Behavioral Health Case Mgr I - West Des Moines, IA - 129961 in West Des Moines, Iowa
/ Your Talent. Our Vision / . At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s the foundation upon which we’re creating greater care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care .
This is an exceptional opportunity to do innovative work that means more to you and those we serve.
BH Case Manager I – West Des Moines, Iowa
This position is responsible for performing telephonic case management within the scope of licensure for members with behavioral health and substance abuse or substance abuse disorder needs. For Medicaid business only, behavioral health case management is performed in the field.
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.
Requires MS or MA in social work, counseling, nursing or a related behavioral health field; 3 years clinical experience in social work, counseling with broad range of experience with complex psychiatric and substance abuse or substance abuse disorder treatment; or any combination of education and experience, which would provide an equivalent background.
- Current active unrestricted license as an RN, LCSW (as applicable by state law and scope of practice), LMHC, LPC (as allowed by applicable state laws), LMFT, or Clinical Psychologist to practice as a health professional within the scope of licensure in applicable states or territory of the United States required.
- Experience in case management and telephonic coaching with members with a broad range of complex psychiatric/substance abuse and/or medical disorders preferred.
/ Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran /
Title: Behavioral Health Case Mgr I - West Des Moines, IA - 129961
Location: IA-West Des Moines
Requisition ID: 129961