Clinical Care Manager II (Union) - Michigan Licensed
Core
Conducts telephone assessments and clinical reviews to determine medical necessity, authorize referrals, and manage care coordination for behavioral health and substance abuse cases.
Role type
Clinical Care Manager (Behavioral Health)
Builds
Care coordination and utilization management decisions for insurance members
Domain
Healthcare / Behavioral Health / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical assessment, telephone triage, medical necessity determination, care coordination, benefit verification, regulatory compliance, case management, provider liaison, quality indicator tracking, ethical decision making
Preferred skills
Inpatient/outpatient care experience, partial hospitalization experience
Technologies
Carelon Behavioral Health Options guidelines, NCQA/URAC standards, EAP systems
Responsibilities
Conduct telephone assessments to gather clinical information and determine appropriate referrals; Review psychiatric and substance abuse cases for medical necessity and render certification decisions; Coordinate care with providers and other managers to ensure continuity; Verify benefit coverage and manage release of benefits based on contract terms; Monitor quality indicators to meet accrediting body requirements; Troubleshoot claims issues and resolve customer complaints regarding care access.
Seniority
Mid-level individual contributor