Senior Case Manager

Job Summary
The Case Management Integration Specialist will be co-located at the customer location all or part of the time and will serve as an integral part of the medical case management team as the expert on behavioural health and medical co-morbidities. The Case Management Integration Specialist (CMIS) will provide support for members who are at risk for significant behavioural events or have severe and/or chronic behavioural/or other co-morbid medical health conditions including poly-pharmacy. CMIS staff is responsible for coordinating behavioural health services to medically compromised members, as well as, education and training to the customer’s medical case management team. These specialists will direct and manage medically complex members’ cases based on established member selection criteria, interventions, and program policies and procedures. The CMIS ensures coordination of services for members with other programs, behavioural health providers, and primary care physicians (PCPs); contributes to overall management of healthcare costs, including behavioural health, through proper application of Medical Necessity Criteria (MNC) and minimizing unnecessary ER visits, potential medication interactions and hospitalization. Their primary goal is to ensure behavioural health support to influence behavioural changes which ultimately result in improved member wellbeing.

Essential Functions
In collaboration with the respective health plan case manager, the CMIS:
Serves as consultant to the customer medical case management teams in identifying behavioral health conditions and treatment options for medically complex cases. Collaborates with other MHS clinical specialty services (i.e., Conditioned Care Management, Enhanced Medical, etc.) to maximize outcomes.
Administers survey screenings and identifies interventions for members, family members, providers, and PCPs to improve member’s ability and/or motivation to self-manage their conditions including education around coordination of medications for both behavioural and medical conditions.
Educates and informs members of treatment options, as well as collaborating with PCPs, Providers, Family Members, and other managed care coordinators to articulate interventions and ensure optimal levels of functional status and wellness
Establishes individualized, measurable plans of treatment in collaboration with members and health plan case managers that address issues such as quality of life, satisfaction with care, functional abilities, effectiveness of treatment and barriers to goal attainment
Identifies and diagnoses medical and behavioral symptoms of members, as well as applies knowledge of potential contraindications and side effects of prescription medication in the development of member treatment plans
Receives inbound and make outreach calls to members in order to ensure appropriate delivery and access to services. Assists in the coordination of medical and behavioral services in complex cases taking into account medical co-morbidities.
Identifies and removes barriers to accessing services and assists members as needed