BEHAVIORAL CASE MANAGER

Lucent Health has an opportunity for an experienced clinician to provide high quality case management services in a comprehensive health care risk management environment. Our case managers are responsible for providing comprehensive and clinically appropriate case management services telephonically to clients with chronic or catastrophic healthcare needs. Behavioral Case Managers will be required to adhere with CMSA Standards of Practice, internal Policies and Procedures, and AAHC/URAC guidelines in the performance of their duties.

Minimum Education Licensure and Professional Certification requirement:

  • Bachelor’s Degree strongly preferred
  • Minimum 5 Years Clinical Nursing Experience
  • UM or Case Management Experience Preferred
  • Current Nursing License – Tennessee, Kentucky, Illinois, Indiana, Florida preferred
  • Team skills
  • Strong communication skills

Expectations

  • Processes claims accurately, efficiently, timely, and within quality/quantity requirements.
  • Exhibits an attention to detail and a strong work ethic.
  • Has the ability to interpret Plan Documents and apply appropriately in the processing of claims.
  • Has the ability to access research tools for accurate claims entry.
  • Organized and manage time and resources efficiently and effectively.
  • Has thorough knowledge and use of coding structures (CPT, HCPCS, Revenue codes, ICD 9/10 etc.)
  • Has the ability to perform arithmetic calculations.
  • Has knowledgeable of COB.
  • Exercises expert knowledge of benefits and benefit calculations.

Minimum Experience Required

  • 2 years previous health insurance claims experience. Working knowledge of coding structures; claims pricing and claims processing.

· Strong understanding of and experience with MAT and ABA

  • Claims pricing (Network, Medicare, RBP (Ref. Based Pricing) experience.
  • Coding structures, CPT, HCPCS, Revenue codes, ICD 9/10, etc. experience or certification required.
  • Strong understanding of claims analyst process and procedures skills.

Required Skills and Abilities

  • Excellent communication, written, telephonic and personal skills
  • Ability to manage and follow through consistently and accurately
  • Attention to detail
  • Completion of all responsibilities in a timely manner
  • Independent thinking
  • Strong Organization Skills

Responsibilities

  • Determine individual needs based on factors such as Medical Condition, Psychological Condition, work history and situation, any payer complications, external resources.
  • Develop a plan that coordinates the appropriate treatment considering the facts of the assessment.
  • Provide the plan member with data to make informed decisions and should suggest alternative forms of treatment or contingencies where possible.
  • Facilitate communication between the member and the care team and obtain approval from all parties whenever possible (member, family, providers, and payers).
  • Providing excellent care based on the decided upon plan to ensure that the desired outcome is reached.
  • Ensure the plan is performing as designed, and to the expectations of all parties.
  • Assist in Identification and Selection, and Termination of the Case Management process as able in cooperation with Claim Analysts.
  • Contact patients to explain Case Management and the associated process.

Lucent Health is an Equal Opportunity Employer.