Clinical Care Manager II at Elevance Health

Dearborn, Michigan, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Behavioral HealthIndustries

Requirements

Professional knowledge of clinical guidelines, Carelon Behavioral Health criteria, and medical necessity standards for psychiatric/substance abuse cases
Scope of practice relevant to the clinical area under review (e.g., assessments, referrals, counseling)
Ability to conduct telephone assessments, collect demographic and clinical information, and make certification decisions
Location within reasonable commuting distance from Dearborn, MI (unless accommodation granted)
Availability for shift: Sunday 7:00am - 3:30pm EST and Monday - Thursday 2:00am - 10:30am EST
Compliance with collective bargaining agreement (CBA) provisions if applicable
Ethical and professional standards, including maintaining confidentiality of clients, records, and reports
Superior telephone service standards and customer service skills
Ability to maintain individual productivity and performance standards

Responsibilities

Conduct telephone assessments to collect clinical information and make appropriate referral and certification decisions for emergency/urgent/routine/EAP referrals
Provide referrals to appropriate providers, therapists, or EAP, including outpatient treatment, and review care for medical necessity
Evaluate clinical appropriateness of treatment using Carelon Behavioral Health guidelines and render certification decisions or seek consultations
Collaborate with providers to determine alternate levels of care and facilitate transfers to network facilities
Coordinate care with other managers to ensure continuity of care
Refer cases not meeting criteria to Peer Advisors or MD/Clinical Management staff
Manage release of MHSA benefits for designated groups
Review proposed treatments and predeterminations for medical necessity
Interface with internal/external customers, troubleshoot claims issues, investigate customer complaints, and resolve problems
Maintain optimal efficiency of service, apply policies/procedures consistently, and contribute to staff meetings, clinical conferences, trainings, and conference calls
Perform special projects and all other duties as assigned

Skills

Clinical Assessments

Telephone Triage

Utilization Review

Care Coordination

Referral Management

Medical Necessity Criteria

Behavioral Health

Provider Collaboration

Certification Decisions

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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