Behavioral Case Manager

· Performs behavioral health triage and crisis management services. Links and coordinates services with medical/surgical departments and other outside agencies, such as transportation and home health care. Coordinates psychiatric diagnoses, behavioral health treatment services, and psychotropic medications with behavioral health providers and physician advisors. Refers members to the appropriate level care and reviews and authorizes care services using InterQual criteria and medical necessity guidelines. Documents treatment authorizations and monitors, tracks and reports behavioral health care utilization.

· Conducts all necessary direct utilization management activities for behavioral health plan members including service coordination for members in crisis, crisis intervention, behavioral health triage, crisis assessment services, pre-certification and authorization of care for both psychiatric and chemical dependency services, all necessary concurrent review with hospitals and mental health centers, discharge and aftercare planning and referrals for continued outpatient care.

· Interacts on a daily basis with hospital representatives and attending psychiatrists and coordinates physician-to-physician reviews with the medical director. Reviews treatment plans and consults with medical director regarding medical necessity criteria for continued inpatient stay. Facilitates community placements, agency linkages and coordinates discharge planning, aftercare, referral and follow-up of inpatients. 

· Documents, monitors, tracks, and reports authorizations, denials, treatment plans, clinical findings, progress notes, and case dispositions related to behavioral health services using automated and manual systems and formats.  

· Monitors, tracks and reports cases. Monitors utilization trends by hospital and attending psychiatrist with emphasis on managing high volume providers.

· Identifies high risk/high volume members for more intensive follow-up care and conducts hand-off coordination between Clinical Coordinators and providers.

· Coordinates community resources with emphasis on the development of natural support system. Coordinates benefits, regulations, laws and public entitlement programs. Applies psychological and counseling theory and industry standard clinical guidelines with the appropriate ICD-9/DSM IV diagnosis. Maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding abuse and neglect.

· Ensures members have access, availability and quality care according to standards.

· Participates in case conferences regarding high risk/high volume regarding provider and hospital issues. Attends and participates in other HBH work groups and meetings as required.

· Responds to incoming telephone calls as assigned, meeting or exceeding the standards for phone access and availability in order to meet the needs of members served by the department.

· Performs all other clinical and administrative duties as assigned.